[MedRec]
[consultation]
[chemotherapy]
[reconciliation]
The FOLFOX regimen was initiated on 2024-01-31. A subsequent evaluation on 2024-02-27 revealed an elevated CA-199 level. This finding might suggest the possibility of disease in the distal stomach (closer to the small intestine).
Additionally, the CRP level on 2024-02-27 was 15.5 mg/dL, while the PCT level was within normal limits. Elevated CRP can indicate various conditions, including inflammation, autoimmune disorders, tissue injury, or even certain cancers. Therefore, further monitoring or investigations may be prudent to elucidate the cause of the elevated CRP.
No medication discrepancies were found after review of HIS5 and PharmaCloud records.
[reconciliation - potential medication discrepancy: refills not aligned with active list]
A potential medication discrepancy has been identified for this patient. While the patient has recently refilled a 28-day supply of lorazepam, escitalopram, and ginkgo biloba extract (ginkgoflavonglycosides) on 2024-02-26 according to the PharmaCloud database, these medications are not currently included in the active medication list. Please verify if these refilled medications are still deemed necessary and consider updating the active medication list accordingly.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[allergy]
[Family History]
[lab data]
[exam findings]
[MedRec]
[immunochemotherapy]
Topotecan - 2024-02-29 - https://www.uptodate.com/contents/topotecan-drug-information
[disease progression after multiple regimens: Enhertu partial response & topotecan consideration]
The patient’s disease progressed after receiving paclitaxel and carboplatin, followed by liposomal doxorubicin and carboplatin. However, a partial response was observed with Enhertu (fam-trastuzumab deruxtecan-nxki. There was NO amplification of HER2 gene detected on 2023-07-26).
Enhertu is an antibody-drug conjugate (ADC) that delivers the topoisomerase I inhibitor payload deruxtecan (DXd). Topotecan, which is currently being used, is also a topoisomerase I inhibitor. Therefore, it is expected that there may still be a response, but with potentially higher adverse reactions.
Neutropenia was observed when Enhertu was previously administered, so close monitoring is recommended.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
Paclitaxel - 2024-02-29 - https://www.uptodate.com/contents/paclitaxel-conventional-drug-information
[FOLFOX followed by paclitaxel: rising tumor markers & hypokalemia]
The patient’s treatment was initiated with the FOLFOX regimen in May 2023. Both CEA and CA199 tumor markers reached their nadir (lowest point) in Sep 2023, but still remained out of the normal reference range. Subsequently, the markers began to rise, and the last dose of FOLFOX was administered in late Nov 2023.
2024-02-27 CEA (NM) 30.060 ng/ml
2024-02-20 CEA (NM) 26.790 ng/ml
2024-01-30 CEA (NM) 24.157 ng/ml
2024-01-19 CEA (NM) 23.317 ng/ml
2023-12-29 CEA (NM) 22.383 ng/ml
2023-12-22 CEA (NM) 17.894 ng/ml
2023-12-15 CEA (NM) 14.477 ng/ml
2023-12-08 CEA (NM) 15.861 ng/ml
2023-12-01 CEA (NM) 14.718 ng/ml
2023-11-17 CEA (NM) 12.991 ng/ml
2023-10-24 CEA (NM) 10.527 ng/ml
2023-10-06 CEA (NM) 8.849 ng/ml
2023-09-28 CEA (NM) 8.549 ng/ml
2023-09-15 CEA (NM) 7.623 ng/ml
2023-09-01 CEA (NM) 7.170 ng/ml
2023-07-07 CEA (NM) 9.071 ng/ml
2023-06-23 CEA (NM) 10.524 ng/ml
2023-06-12 CEA (NM) 11.251 ng/ml
2023-06-02 CEA (NM) 14.962 ng/ml
2023-05-30 CEA (NM) 15.930 ng/ml
2023-04-27 CEA 28.09 ng/mL
2024-02-27 CA-199 (NM) 735.100 U/ml
2024-02-20 CA-199 (NM) 669.050 U/ml
2024-01-30 CA-199 (NM) 754.580 U/ml
2024-01-19 CA-199 (NM) 598.990 U/ml
2023-12-29 CA-199 (NM) 382.890 U/ml
2023-12-22 CA-199 (NM) 202.647 U/ml
2023-12-15 CA-199 (NM) 178.155 U/ml
2023-12-08 CA-199 (NM) 203.365 U/ml
2023-12-01 CA-199 (NM) 171.744 U/ml
2023-11-17 CA-199 (NM) 156.577 U/ml
2023-10-24 CA-199 (NM) 126.428 U/ml
2023-10-06 CA-199 (NM) 96.780 U/ml
2023-09-28 CA-199 (NM) 84.503 U/ml
2023-09-15 CA-199 (NM) 93.263 U/ml
2023-09-01 CA-199 (NM) 89.666 U/ml
2023-07-07 CA-199 (NM) 122.765 U/ml
2023-06-23 CA-199 (NM) 147.885 U/ml
2023-06-12 CA-199 (NM) 197.215 U/ml
2023-06-02 CA-199 (NM) 250.810 U/ml
2023-05-30 CA-199 (NM) 363.860 U/ml
2023-04-27 CA-199 260.84 U/mL
Paclitaxel was initiated on 2024-01-26. Ramucirumab, originally planned as a co-administered drug, has not yet been commenced. The paclitaxel treatment has not shown a clear trend of decreasing tumor marker levels.
Hypokalemia was identified on 2024-02-28, with a value of 2.9 mmol/L. Const-K and Spiron (spironolactone) are currently being administered, and no medication discrepancies were found.
[exam findings]
[MedRec]
[immunochemotherapy]
[leukopenia]
The patient received the Keytruda (pembrolizumab) with AC(Lipo) regimen on 2023-08-15, 2023-09-06, 2023-09-28, and 2023-10-18, with episodes of leukopenia noted in early Sep and early Oct.
The frequency of the immunochemotherapy was Q3W, and the second episode of leukopenia was more severe than the first. This may indicate that the patient’s recovery capacity is not keeping pace with the immunosuppressive effects of the medication.
Under the National Health Insurance drug reimbursement regulations, short-acting injectables G-CSF such as filgrastim and lenograstim can be used in non-hematologic malignancy patients post-chemotherapy if they have experienced white blood cell counts below 1000/cumm or absolute neutrophil counts (ANC) below 500/cumm. The patient’s lab values have not yet reached these thresholds. If there is a consideration of increased risk of infection, it may be advisable for the patient to use these medications at their own expense.
Compared to other options such as lowering the dose of chemotherapy or increasing the administration interval, the use of G-CSF appears to be a more effective approach in managing neutropenia caused by chemotherapy. Lowering the dose of chemotherapy may reduce the occurrence of neutropenic complications, but it can also compromise the effectiveness of the treatment (Lyman et al., 2005). Similarly, increasing the administration interval of chemotherapy may reduce the frequency of neutropenia, but it can also lead to delays in treatment and potentially compromise treatment outcomes (Okera et al., 2010). On the other hand, the use of G-CSF has been shown to effectively prevent and manage neutropenia, reducing the risk of febrile neutropenia, infections, and the need for dose reductions or delays in treatment (Ar, 2004; Crawford, 2003; Mizuno et al., 2017; Flores & Ershler, 2010).
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[Xeloda (capecitabine) tube feeding]
Steps to dissolve the Xeloda tablets (Ref: https://www.enherts-tr.nhs.uk/wp-content/uploads/2019/10/Capecitabine-v1-final.pdf)
Important - Capecitabine tablets should never be crushed - this creates a dangerous dust.
Protection - The person preparing the solution should wear non-sterile gloves and a non-sterile plastic apron (supplied by the hospital).
Capecitabine can be slowly but completely dissolved. It can be used with a gastric or jejunal feeding tube. (Ref: Developing guidance for feeding tube administration of oral medications. JPEN J Parenter Enteral Nutr. 2023 May;47(4):519-540. doi: 10.1002/jpen.2490)
[patient education]
After attending a family meeting with the patient’s relatives at 11:00 this morning, I visited the patient at 12:30. At that time, the patient and his wife had left the bed to walk nearby, only the patient’s daughter was present. I told the patient’s daughter that if immunotherapy is to be used, it is better to use it sooner rather than later. The patient’s daughter also asked about the possible prognosis of the disease and the possible side effects of the drugs. I elaborated based on the content of this morning’s family meeting. The patient’s daughter indicated that she will decide whether to use immunotherapy in the near future.
[exam findings]
[MedRec]
[surgical operation]
[immunochemotherapy]
[reconciliation]
Throughout this hospitalization, the patient has maintained stable vital signs. Lab tests obrained on 2024-02-26 revealed grossly normal readings. Based on these findings, no contraindications to the administration of trastuzumab plus docetaxel were identified. Additionally, a review of the HIS5 and PharmaCloud revealed no discrepancies.
[exam findings]
[MedRec]
[consultation]
[immunochemotherapy]
dose-adjusted (da)-R-EPOCH - Infusional etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R) for non-Hodgkin lymphoma - 2024-01-25 - https://www.uptodate.com/contents/image?imageKey=ONC%2F88411
[anemia]
Lab results obtained on 2024-02-26 were unremarkable except for a stool occult blood test 1+ and anemia (HGB 7.7 g/dL). The anemia was subsequently addressed with a LPRBC transfusion.
No lab findings were identified that would preclude administration of the R-da-EPOCH regimen.
[monitoring iron levels in this frequent transfusion patient]
The laboratory results suggest a consistent pattern of microcytosis/microcytic anemia. This patient has been receiving multiple blood transfusions approximately monthly since Sep 2023. Given this history, it is advisable to assess iron storage to evaluate for potential iron overload if clinically necessary.
[reconciliation]
Lab results obtained on 2023-12-26 revealed no significant abnormalities that would contraindicate the continuation of the R-da-EPOCH regimen. Additionally, comprehensive medication reviews using HIS5 and PharmaCloud identified no discrepancies in the current medication list.
[prophylactic G-CSF for post-chemotherapy leukopenia]
The patient was admitted to begin the 3rd cycle of R-da-EPOCH chemotherapy on 2023-11-27. Based on the experiences from cycles 1 and 2 of this regimen, leukopenia may occur following this administration. Prophylactic G-CSF can be prescribed for standby use.
There are no medication reconciliation issues after review of PhamaCloud and HIS5 records.
The patient has received two cycles of R-CHOP treatment and has then transitioned to DA-R-EPOCH treatment as of 2023-10-06. It is believed that the new treatment, R-DA-EPOCH, is more effective but also carries a higher risk of toxicity. As the patient has recently started this new regimen, please closely monitor for any signs of adverse reactions. Ref: DA-R-EPOCH vs R-CHOP in DLBCL: How do we choose? Clin Adv Hematol Oncol. 2021 Nov;19(11):698-709. PMID: 34807015; PMCID: PMC9036549.
An episode of leukopenia was observed on 2023-09-05, approximately two weeks after the patient’s initial R-CHOP regimen administered on 2023-08-24. Prompt intervention with a consecutive 3-day course of G-CSF was initiated, and since then, no further instances of leukopenia have been detected.
[lab data]
2023-12-06 P.jiroveci DNA-Sp Positive
2023-12-04 CMV viral load assay Target not detecetedIU/mL
2023-11-30 Aspergillus Ag Negative
2023-11-30 Aspergillus Ag Value 0.1 Ratio
2023-11-29 ANA Negative
2023-11-29 Mycoplasma pneumonia IgG Negative AU/mL
2023-11-29 Mycoplasma IgG Valu <10 AU/ml
2023-11-28 Anti-ds DNA Antibody <0.6 IU/ml
2023-11-28 Anti-ENA SS-A (Ro) <0.4 EliA U/ml
2023-11-28 Anti-ENA SS-B (La) <0.3 EliA U/ml
2023-11-28 Anti Jo-1 antibody <0.3 EliA U/ml
2023-11-28 Anti-ENA Scl-70 Ab <0.6 EliA U/ml
2023-11-28 Anti-ENA Sm <0.8 EliA U/ml
2023-11-28 Anti-ENA RNP <0.5 EliA U/ml
2023-11-28 Cryptococcus Ag Negative
2023-11-28 RF <10 IU/mL
2023-11-26 COVID19新冠肺炎病毒抗原快篩 Negative
2023-11-26 Influenza A Ag Negative
2023-11-26 Influenza B Ag Negative
2023-08-08 Anti-HCV (NM) Negative
2023-08-08 Anti-HCV Value (NM) 0.042
2023-08-08 Anti-HBc (NM) Negative
2023-08-08 Anti-HBc Value (NM) 2.360
2023-08-08 Anti-HBs (NM) Positive
2023-08-08 Anti-HBs value (NM) 210.000 mIU/mL
2023-08-08 HBsAg (NM) Negative
2023-08-08 HBsAg Value (NM) 0.432
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[addressing post-chemotherapy respiratory distress and leukopenia]
Currently, there are no recent daily progress notes in HIS5 found.
Should there be recent occurrences of dyspnea, respiratory distress, or shortness of breath, it’s important to note that the last chemotherapy session with docetaxel was on 2023-11-16, about two weeks ago. Therefore, it is less probable that these symptoms are directly caused by the chemotherapy (hypersensitivity). However, docetaxel has also been linked to pulmonary disease, unspecified, with a reported incidence rate of 41% (Ref: UpToDate).
Another potential cause that cannot be overlooked is the earlier administration of cyclophosphamide, a component of the AC(Lipo) regimen. This drug has been associated with pulmonary toxicity, manifesting in various forms such as pneumonitis, pulmonary fibrosis, pulmonary veno-occlusive disease, and acute respiratory distress syndrome. Identifying pulmonary toxicity can be challenging due to overlapping pulmonary conditions in the same patient population, including infections and pulmonary malignancies. Symptoms of this toxicity typically include dyspnea, fever, cough, parenchymal infiltrates, abnormal pulmonary function tests, and pleural thickening.
If nonspecific interstitial pneumonia (NSIP) has been confirmed (and assuming that infection has been completely excluded as a cause), it is recommended to begin with prednisone 0.5 to 1 mg/kg ideal body weight per day up to a maximum of 60 mg/day for one month followed by 30 to 40 mg/day for an additional two months.
For patients with severe NSIP, pulse intravenous methylprednisolone may be preferred for initial therapy. A typical regimen is 1000 mg/day for three days followed by oral prednisone as dosed above. Rarely, patients need additional pulse doses.
Additionally, there was an episode of leukopenia in late Nov (WBC counts 1.69K/uL on 2023-11-22 and 2.84K/uL on 2023-11-26), which might have been caused by the administration of docetaxel. It may be an option to prepare prophylactic G-CSF for use after the next chemotherapy session.
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[reconciliation]
Vital signs during this hospital stay and labs on 2024-02-27 showed stable and normal values, no medication discrepancy found after reviewing HIS5 and PharmaCloud.
[reconciliation]
Lab data from 2024-02-01 and vital signs assessed through the TPR panel during this hospital stay were overall within normal limits. A thorough review of the HIS5 and PharmaCloud databases did not reveal any discrepancies in medication.
[gradual eGFR change: current dose safe, continued monitoring]
There appears to be a gradual downward trend in eGFR in this patient, and no dose adjustment is required at this time.
[tube feeding: Const-K extended-release tab 750mg/10mEq/tab (KCl); Detrusitol SR 4mg prolonged-release cap (tolterodine); Wellbutrin XL 150mg/tab (bupropion)]
Const-K is an extended-release potassium supplement tablet that is not intended to be crushed, as this would compromise its slow-release properties. However, in situations where oral administration is not feasible and intravenous potassium is not preferred, crushing the tablet for tube feeding might be considered the only option, despite the loss of extended-release functionality.
Each Const-K tablet delivers 10 mEq of potassium, equating to the potassium content of approximately a 10 cm banana, which contains about 2.2 mEq/inch (0.9 mEq/cm) in bananas (N Engl J Med. 1985;313(9):582.)
Similarly, other extended-release medications such as Detrusitol SR and Wellbutrin XL are not recommended to be crushed. Disrupting their extended-release mechanism can lead to more variable serum concentrations, potentially affecting their efficacy and safety.
[exam findings]
[MedRec]
[chemotherapy]
[nab-paclitaxel and renal function]
Post-administration of nab-paclitaxel, serum creatinine levels have consistently remained above 1.5 mg/dL. Although there hasn’t been a rapid increase, continuous monitoring is still advised.
Nab-Paclitaxel for patients with altered kidney function, there are no dosage adjustment recommendations for those with a Creatinine Clearance (CrCl) ≥30 mL/minute. Furthermore, there are no pharmacokinetic studies available for severe kidney impairment in patients with a CrCl <30 mL/minute.
[past history]
[allergy]
[family history]
[exam findings]
[chemoimmunotherapy]
[guidelines for platelet transfusion addressing thrombocytopenia in Kadcyla therapy]
The patient has been on Kadcyla (trastuzumab emtansine) therapy since 2023-06-26, following a previous regimen that included Herceptin (trastuzumab) and Perjeta (pertuzumab), with the last dose administered on 2023-05-17.
Post-initiation of Kadcyla, there has been a temporal association with an increase in both the frequency and severity of thrombocytopenia episodes, indicating that the thrombocytopenia could be attributed to Kadcyla. Literature indicates that trastuzumab emtansine is associated with thrombocytopenia, with incidences ranging from 29% to 31%, and grades 3/4 thrombocytopenia occurring in 6% to 15% of cases, including a higher incidence in patients of Asian descent, where grades 3/4 thrombocytopenia ranges from 19% to 45%.
Prophylactic platelet transfusions are recommended to prevent spontaneous bleeding in afebrile patients with platelet counts below 10K/uL due to bone marrow suppression. This recommendation aligns with guidelines from the International Society on Thrombosis and Haemostasis published in 2023 (Reference: J Thromb Haemost. 2024;22(1):53).
In patients presenting with fever, infection, or inflammation, platelet transfusions are generally advised at counts of ≤ 15K to 20K/uL due to the heightened risk of bleeding (Reference: Clin Lab Med. 2021;41(4):621).
There are currently no bowel movement records for this hospital stay in HIS5. However, the records from the patient’s previous hospital stay (between 2023-01-31 and 2023-02-01) indicated that the patient had one bowel movement per day.
According to the review of systems in the admission note for this hospital stay, the patient experienced diarrhea and had 8 to 9 bowel movements per day.
It might be noted that docetaxel is known to cause gastrointestinal adverse reactions, including diarrhea (with a frequency of 23% to 43%, and severe diarrhea occurring in 6% or less of cases), and the incidence of diarrhea with pertuzumab and trastuzumab is 60% (ref: UpToDate).
The use of loperamide is recommended as a means of alleviating diarrhea and Loperamide (2mg/cap) is available in this hospital.
Loperamide usage: Oral, Initial: 4 mg, followed by 2 mg every 2 to 4 hours or after each loose stool; for diarrhea persisting >24 hours, administer 2 mg every 2 hours (or 4 mg every 4 hours). Continue until 12 hours have passed without a loose bowel movement. Doses >16 mg/day may not provide benefit; consider alternative therapy for diarrhea persisting >=48 hours.
[MedRec]
[reconciliation]
According to the PharmaCloud database, there are no outstanding prescriptions issued by other healthcare provider.
Two drugs, Relinide (repaglinide) and Januvia (sitagliptin), prescribed by our endocrinologist on 2024-02-22, are not reflected in the active medication list. It is recommended to verify whether these medications are no longer required.
[exam findings]
[MedRec]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
Why give Taxol (Paxel) before carboplatin? - 2024-02-26 - https://www.drugs.com/medical-answers/give-taxol-paxil-before-carboplatin-3562689/
Medically reviewed by Carmen Pope, BPharm. Last updated on Oct 2, 2023.
Official answer by Drugs.com
Why is Taxol and carboplatin used together?
How effective is Taxol and carboplatin?
No repeat prescriptions have been issued by any healthcare provider other than ours according the the PharmaCloud database. Furthermore, the medications prescribed by our cardiologist on 2024-02-01 have been incorporated into the active medication list without any discrepancies.
The patient’s vital signs have remained stable throughout this hospital stay, and laboratory results from 2024-02-26 did not reveal any significant findings. There is no evidence to suggest any contraindications for the administration of the paclitaxel and carboplatin regimen.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
Small Cell Lung Cancer NCCN Evidence Blocks - Version 1.2024 - 2023-09-05
Carboplatin plus etoposide for chemotherapy-naïve extensive-stage small cell lung cancer 2023-06-02 https://www.uptodate.com/contents/image?topicKey=ONC%2F4633&imageKey=ONC%2F75586
Cycle length: 21 days, for a maximum of six cycles.
Regimen
Pretreatment considerations:
Monitoring parameters:
Suggested dose modifications for toxicity:
[evaluating elevated conjugated bilirubin and potential obstructions]
The level of conjugated bilirubin is elevated, which may indicate obstructions such as gallstones or strictures in the bile ducts, hindering the excretion of bilirubin into the gastrointestinal tract. Abdominal ultrasonography conducted on 2023-07-27 revealed potential chronic liver parenchymal disease and a suspected gallbladder stone. The examination of the liver, particularly the subcostal view, was suboptimal due to a poor echo window.
It may be advisable to request a follow-up abdominal ultrasonography and an Alpha-Fetoprotein (AFP) test for further evaluation.
[monitoring pneumonitis risk: durvalumab/carboplatin for stable patchy consolidation]
Comparing the CXR 2024-01-03, to 2024-01-31, the patchy consolidation in the left middle lung has not become more pronounced. On 2024-01-31, a new session of durvalumab combined with carboplatin was administered. Continuous monitoring of the pulmonary condition is recommended.
Pneumonitis includes acute interstitial pneumonitis, interstitial lung disease, pneumonitis, pulmonary fibrosis is associated with Imfinzi (durvalumab), according to the package insert (https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/761069s035lbl.pdf page 12-13; all grades 34%, grade 3/4 3.4%).
Vital signs and lab results were grossly normal except for elevated AST, ALT and bilirubin levels, no medication discrepancies noted.
[reconciliation]
The admission note dated 2024-01-02 recorded an ECOG PS of 2. The original regimen was designed as “carboplatin AUC 5-6 on day 1 and etoposide 80-100 mg/m2 on days 1, 2, 3, along with durvalumab 1500 mg on day 1 every 21 days for 4-6 cycles, followed by maintenance durvalumab 1500 mg on day 1 every 28 days.” However, due to the patient’s apparent frailty, since Oct 2023, the regimen was modified to a reduced dose version with carboplatin AUC 2 and etoposide omitted. The CT results from 2023-12-28 still indicate an effective disease control.
Lab data from 2024-01-02 showed slightly elevated ALT (42 U/L) and creatinine (1.32 mg/dL) levels. Current medications do not require dose adjustments based on these readings.
The patient is currently taking several medications with no discrepancies noted: From our neurologist (as of 2023-08-31) for Syntam (piracetam), Lixiana (edoxaban), and Mesyrel (trazodone); from the chest physician (as of 2023-08-31) for Xanthium (theophylline), Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), and Mecater (procaterol); and from the cardiologist (as of 2023-08-09) for Cartil (diltiazem).
The previously observed spikes in AST and ALT levels in May and July/August of this year have now disappeared. Renal function tests show normal results and no drug dose adjustments are required based on liver and kidney function.
The serum potassium level dropped to 3.1 mmol/L on 2023-10-05, the lowest level recorded in the last three months. This may warrant further monitoring.
Per the HIS5 records, medications issued as repeat prescriptions by our departments of Neurology, Chest Medicine, and Cardiology on 2023-08-31, 2023-08-31, and 2023-08-09 respectively, are all accounted for in the active medication list. No discrepancies in medication reconciliation have been found.
The patient visited our Psychosomatic Medicine OPD on 2023-05-11 and 2023-05-25, where he was prescribed Zoloft (sertraline), which was duly added to the list of active medications. In addition, the patient has a refillable prescription for Lixiana (edoxaban) from our Neurology OPD dated 2023-04-13, which also appears on the active medication list.
It’s advised to note that selective serotonin reuptake inhibitors (SSRIs), such as sertraline, can potentially increase the risk of bleeding, especially when used with antiplatelet and/or anticoagulant medications. There have been several observational studies linking the use of SSRIs to a variety of bleeding complications, ranging from minor problems such as bruising, hematoma, petechiae, and purpura to more serious conditions such as stroke, upper gastrointestinal bleeding, intracranial hemorrhage, postpartum hemorrhage, and perioperative bleeding. In light of this, it is prudent to monitor this patient closely for any signs of bleeding.
The liver-associated enzymes ALT and AST, particularly ALT, have both shown an increasing trend in this patient. The patient is currently being treated with Baogan (silymarin) and Baraclude (entecavir), which are appropriate given the patient’s liver status and HBV carrier state.
Etoposide has been associated with hepatotoxicity, but the incidence is low (<= 3%) and therefore it is less likely to be the primary cause of the elevated liver enzymes. On the other hand, carboplatin is reported to be associated with increased serum alkaline phosphatase (24% to 37%) and increased serum aspartate aminotransferase (15% to 19%). This suggests that carboplatin might be a more likely cause of the observed liver enzyme elevation.
Given that the patient’s current regimen has already been dose-reduced since initiation (etoposide from 100mg/m2 to 80mg/m2, carboplatin from AUC 5 to AUC 4), it may not be necessary to further reduce the dose immediately unless the liver enzymes rapidly increase.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[reconciliation]
The patient’s vital signs remain stable. However, lab results on 2024-02-22 indicate renal insufficiency. Consequently, the dosage of Keppra (levetiracetam) listed in the active medication list should be adjusted to reflect renal function. The current dose of 500mg BID falls within the recommended range for patients with a CrCl of 50 to 80. No medication discrepancies were identified.
[kidney concerns prompt cisplatin swap: carboplatin steps in]
Despite receiving normal saline hydration 1L before and 1L after each cisplatin dose (reduced to 75mg/m2, standard 100mg/m2), the patient experienced elevations in both serum creatinine and BUN values following initiation of etoposide and cisplatin therapy on 2023-08-21.
2023-12-25 Creatinine 1.70 mg/dL
2023-12-22 Creatinine 2.07 mg/dL
2023-12-01 Creatinine 1.63 mg/dL
2023-11-29 Creatinine 1.91 mg/dL
2023-11-15 Creatinine 1.88 mg/dL
2023-10-31 Creatinine 1.91 mg/dL
2023-10-17 Creatinine 0.88 mg/dL
2023-09-27 Creatinine 1.27 mg/dL
2023-09-18 Creatinine 0.71 mg/dL
2023-08-31 Creatinine 0.78 mg/dL
2023-08-21 Creatinine 0.70 mg/dL
2023-08-14 Creatinine 0.67 mg/dL
2023-08-11 Creatinine 0.62 mg/dL
2023-08-09 Creatinine 0.84 mg/dL
2023-08-08 Creatinine 0.64 mg/dL
2023-08-02 Creatinine 0.80 mg/dL
2023-12-25 BUN 30 mg/dL
2023-12-22 BUN 27 mg/dL
2023-12-01 BUN 37 mg/dL
2023-11-29 BUN 41 mg/dL
2023-11-15 BUN 42 mg/dL
2023-10-31 BUN 46 mg/dL
2023-10-17 BUN 13 mg/dL
2023-09-27 BUN 30 mg/dL
2023-09-18 BUN 14 mg/dL
2023-08-31 BUN 18 mg/dL
2023-08-21 BUN 21 mg/dL
2023-08-14 BUN 17 mg/dL
2023-08-11 BUN 11 mg/dL
2023-08-09 BUN 12 mg/dL
2023-08-08 BUN 12 mg/dL
2023-08-02 BUN 15 mg/dL
To minimize the risk of further kidney damage, considering a switch from cisplatin to carboplatin (AUC 5) in the treatment plan could be beneficial, as carboplatin is known to have less impact on kidney function.
Ref: - Comparison of Carboplatin With Cisplatin in Small Cell Lung Cancer in US Veterans. JAMA Netw Open. 2022 Oct 3;5(10):e2237699. doi: 10.1001/jamanetworkopen.2022.37699. Erratum in: JAMA Netw Open. 2023 Jan 3;6(1):e2246257. PMID: 36264573; PMCID: PMC9585434. - Etoposide phosphate with carboplatin in the treatment of elderly patients with small-cell lung cancer: a phase II study. Ann Oncol. 2001 Jul;12(7):957-62. doi: 10.1023/a:1011171722175. PMID: 11521802.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
TS-1
[leukopenia & thrombocytopenia following chemotherapy: monitoring PLT for Transfusion]
Gemcitabine, cisplatin, and TS-1 combination chemotherapy was initiated in 2023-08. The disease remained stable until a CT scan performed on 2024-02-16 revealed multiple liver metastases and carcinomatosis, indicating disease progression. Consequently, the treatment regimen was switched to FOLFOX, which was first administered during this hospitalization.
Leukopenia and thrombocytopenia developed following the last dose of gemcitabine, cisplatin, and TS-1 on 2024-02-15.
2024-02-23 WBC 3.45 x10^3/uL
2024-02-21 WBC 1.62 x10^3/uL
2024-02-19 WBC 4.13 x10^3/uL
2024-02-15 WBC 5.56 x10^3/uL
2024-02-23 PLT 48 *10^3/uL
2024-02-21 PLT 78 *10^3/uL
2024-02-19 PLT 102 *10^3/uL
2024-02-15 PLT 184 *10^3/uL
The WBC count has since recovered to 3.45 K/uL; however, the PLT count remains low at 48 K/uL. If the bleeding risk is assessed as high, leukocyte-reduced packed red blood cell (LRP) transfusion may be necessary.
[leukopenia]
Granocyte (lenograstim) was administered on 2024-01-11. Subsequently, the WBC nadir, occurred on 2024-01-18. However, by 2024-01-19, this nadir had resolved, indicating a recovery in WBC count.
[gemcitabine + cisplatin: success might falter as markers surge]
The gemcitabine + cisplatin treatment started on 2023-08-25 and continues, but lab results from 2024-01-09 show record highs for both CEA and CA199 markers. This could potentially indicate developing resistance in the disease.
2024-01-09 CEA (NM) 26.176 ng/ml
2023-12-12 CEA (NM) 18.186 ng/ml
2023-12-05 CEA (NM) 21.272 ng/ml
2023-11-14 CEA (NM) 16.023 ng/ml
2023-11-07 CEA (NM) 19.729 ng/ml
2023-10-24 CEA (NM) 12.994 ng/ml
2023-10-09 CEA (NM) 12.462 ng/ml
2023-09-26 CEA (NM) 7.880 ng/ml
2023-09-19 CEA (NM) 6.288 ng/ml
2023-08-15 CEA (NM) 18.890 ng/ml
2024-01-09 CA-199 (NM) 59.203 U/ml
2023-12-12 CA-199 (NM) 45.760 U/ml
2023-12-05 CA-199 (NM) 51.454 U/ml
2023-11-14 CA-199 (NM) 45.873 U/ml
2023-11-07 CA-199 (NM) 40.871 U/ml
2023-10-24 CA-199 (NM) 42.186 U/ml
2023-10-09 CA-199 (NM) 45.064 U/ml
2023-09-26 CA-199 (NM) 31.407 U/ml
2023-09-19 CA-199 (NM) 33.127 U/ml
2023-08-15 CA-199 (NM) 26.597 U/ml
This patient’s PharmaCloud is currently inaccessible. After reviewing the HIS5 records, no medication reconciliation issues were identified.
[exam findings]
[MedRec]
[immunochemotherapy]
[note]
Hairy Cell Leukemia SUGGESTED TREATMENT REGIMENS - NCCN Evidence Blocks - Version 1.2023 - 2022-10-13 — HCL-A 1 OF 2, p7
Cladribine 2023-07-13 https://www.uptodate.com/contents/cladribine-drug-information
Rituximab 2023-07-13 https://www.uptodate.com/contents/rituximab-intravenous-including-biosimilars-drug-information
Anemia with HGB at 7.6 was observed on 2024-02-19, LPRBC transfusion was then carried out.
[thrombocytopenia]
The patient’s thrombocytopenia was present even before the two most recent rounds of immunochemotherapy (rituximab with cladribine administered on 2023-07-07 and 2023-09-07). The primary treatment has been blood transfusions, which were conducted on the following dates: 2023-07-04, 2023-07-22, 2023-07-27, 2023-07-31, 2023-08-07, 2023-08-28, 2023-09-09, and 2023-09-13.
2023-09-13 PLT 43 10^3/uL 2023-09-11 PLT 34 10^3/uL 2023-09-09 PLT 38 10^3/uL 2023-09-06 PLT 41 10^3/uL 2023-09-05 PLT 43 10^3/uL 2023-08-28 PLT 42 10^3/uL 2023-08-23 PLT 29 10^3/uL 2023-08-22 PLT 26 10^3/uL 2023-08-15 PLT 25 10^3/uL 2023-08-09 PLT 120 10^3/uL 2023-08-07 PLT 26 10^3/uL 2023-08-03 PLT 91 10^3/uL 2023-08-01 PLT 24 10^3/uL 2023-07-31 PLT 31 10^3/uL 2023-07-27 PLT 36 10^3/uL 2023-07-25 PLT 50 10^3/uL 2023-07-21 PLT 25 10^3/uL 2023-07-19 PLT 50 10^3/uL 2023-07-18 PLT 92 10^3/uL 2023-07-16 PLT 120 10^3/uL 2023-07-14 PLT 23 10^3/uL 2023-07-12 PLT 40 10^3/uL 2023-07-10 PLT 75 10^3/uL 2023-07-07 PLT 122 10^3/uL 2023-07-05 PLT 19 10^3/uL 2023-07-04 PLT 23 10^3/uL 2023-06-29 PLT 23 10^3/uL 2023-04-06 PLT 87 10^3/uL 2023-02-09 PLT 132 10^3/uL 2022-11-03 PLT 180 10^3/uL
[leukopenia]
The recent WBC nadir was noted on 2023-07-10 with a count of 0.88K/uL, and by 2023-07-12, an increase to 1.21K/uL was evident.
The patient received the regimen of cladribine plus rituximab on 2023-07-07. It’s well known that cladribine injection often leads to dose-dependent myelosuppression (manifested as neutropenia, anemia, and thrombocytopenia), typically reversible. Additionally, rituximab is associated with an incidence of neutropenia (8% to 14%; grades 3/4: 4% to 49%). As such, the regimen could be the primary cause of the patient’s recent leukopenia.
Given the current trend of increasing WBC count without the administration of G-CSF, it would be advisable to continue monitoring over the next few days to verify if the developed leukopenia is resolved.
[thrombocytopenia]
(this pharmacist note is a continuation of the previous one)
Even as the WBC count gradually recovers, platelet levels continue to decline, noted at 40K/uL on 2023-07-12. If this decrease continues, it is typically recommended to consider transfusion if the platelet count drops to or below a threshold of 10K/uL. If fever, sepsis, or coagulopathy is present, higher thresholds may be needed.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
2024-02-22 - nivolumab 3mg/kg 100mg NS 100mL 1hr (Opdivo + Stivarga (regorafenib))
2024-02-05 - nivolumab 3mg/kg 100mg NS 100mL 1hr (Opdivo + Stivarga (regorafenib))
2024-01-11 - bevacizumab 5mg/kg 200mg NS 100mL 90min (Avastin + Lonsurf (trifluridine, tipiracil))
2023-12-23 - bevacizumab 5mg/kg 200mg NS 100mL 90min (Avastin + Lonsurf (trifluridine, tipiracil))
2023-11-01 - bevacizumab 5mg/kg 200mg NS 100mL 90min (Avastin + Lonsurf (trifluridine, tipiracil))
2023-10-09 - FOLFIRI
2023-09-12 - FOLFIRI
2023-08-15 - FOLFIRI
2023-07-25 - FOLFIRI
2023-07-05 - irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI Q2W)
2023-06-09 - irinotecan 120mg/m2 160mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI Q2W)
2024-02-05 ~ undergoing (2024-02-23) - Stivarga (regorafenib 40mg)
2023-10-30 ~ 2024-02-02 - Lonsurf (trifluridine 15mg, tipiracil 7.065mg) 3# BID
Systemic therapy for nonoperable metastatic colorectal cancer: Approach to later lines of systemic therapy - 2024-02-23 - https://www.uptodate.com/contents/systemic-therapy-for-nonoperable-metastatic-colorectal-cancer-approach-to-later-lines-of-systemic-therapy
[regorafenib and nivolumab: evaluating adverse skin reactions]
Stivarga (regorafenib) has been associated with skin rash occurrences in 26% to 30% of cases. Given that this medication has been administered since 2024-02-05 and the onset of skin rash was noted on 2024-02-18, a causal relationship cannot be ruled out.
Dermatologic toxicities, such as immune-mediated rashes including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN, some instances fatal), exfoliative dermatitis, and bullous pemphigoid, may be induced by nivolumab. The mechanism is not dose-related and remains unclear. Typically, dermatologic toxicity presents early in the course of treatment with nivolumab, with a median onset time ranging from 2.8 to 6.1 weeks post-treatment initiation, and can affect patients with any type of tumor. The median onset time for symptoms resembling Sjögren’s disease is approximately 70 days. Therefore, considering the skin rash appeared merely two weeks after starting nivolumab, it is improbable that nivolumab is the cause.
[strategies for weight management during chemotherapy]
The patient, undergoing treatment with Avastin and Lonsurf, has maintained a body weight of approximately 40kg since Mar 2023, experiencing a decline to 38kg in the last week.
Lonsurf is known to contribute to decreased appetite (reported in 34% to 39% of cases) and diarrhea (reported in 23% to 32% of cases, with grades 3/4 severity in 3%).
Considering these side effects, the introduction of megestrol may be beneficial in addressing the patient’s weight loss.
[UTI follow-up]
[MedRec]
[consultation]
[variceal bleeding, hepatic encephalopathy & hypokalemia: multifaceted management approach]
Variceal bleeding has resulted in low hemoglobin (7.6 g/dL on 2024-02-22). Symptomatic anemia might necessitate LPRBC transfusion.
Currently, the patient is receiving IV Glypressin (terlipressin acetate), Hemoclot (tranexamic acid), and Panzolec (pantoprazole).
Serum ammonia level reached 92 µmol/L on 2024-02-21, indicating hepatic encephalopathy. Lactul (lactulose) is being administered to reduce ammonia levels.
Serum potassium measured 3.5 mmol/L on 2024-02-22, placing it at the lower end of the reference range. Studies have demonstrated that hypokalemia can increase renal tubular ammonia production, leading to elevated levels in both the tubular lumen and peritubular capillaries. This effect is partially attributed to intracellular acidosis within renal tubular cells, which stimulates ammonia production from glutamine. While appropriate in the context of metabolic acidosis, this mechanism can become clinically significant in patients with advanced cirrhosis, potentially contributing to hepatic encephalopathy.
Therefore, maintaining serum potassium levels within the middle of the reference range may be beneficial in patients with hepatic encephalopathy to minimize this potential complication.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[evaluating appetite stimulants in patient care]
Social service staff member Luo YuQuan visited the patient on 2024-02-22 and observed that the patient reported recent feelings of lethargy and fatigue. Additionally, the patient’s wife indicated that he has experienced a loss of appetite.
Considering these symptoms, the addition of the appetite stimulant megestrol could be beneficial for improving the patient’s condition, provided there are no contraindications to its use.
[exam findings] (not completed)
[MedRec]
[immunochemotherapy]
[evaluating liver function in the context of metastatic disease]
A CT scan conducted on 2024-02-07 revealed multiple liver metastases indicative of progressive disease. Consequently, the treatment regimen was transitioned to FOLFOX from Avastin + FOLFIRI, the latter having been administered since the third quarter of 2022.
Abnormal LFT results may reflect the metastatic burden. Both Baraclude and GaoGan are currently being administered, with no discrepancies found in the medication regimen.
[exam findings]
[MedRec]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
Clinical presentation and management of thymoma and thymic carcinoma - 2023-11-01 - https://www.uptodate.com/contents/clinical-presentation-and-management-of-thymoma-and-thymic-carcinoma
[chronic anemia worsens with chemo: LPRBC transfusion for the patient]
Lab data on 2024-02-19 showed HGB 7.5 g/dL and an immediate LPRBC transfusion was performed. Vital signs are currently stable.
This patient has a long history of anemia even before the initiation of chemotherapy, but the chemotherapy treatment dose associated with lowered HGB level on a long-term basis.
[regimen change prompts eGFR decline: further monitoring needed]
Following a switch to docetaxel + cisplatin on 2023-12-20 from the previous paclitaxel + carboplatin regimen, the patient has experienced a preliminary decline in eGFR.
While the current eGFR remains within the acceptable range, further monitoring is necessary to track potential changes.
[observing potential thrombosis after previous event]
A thrombotic event previously occurred in mid-Dec 2023, and a recent slight elevation in D-dimer levels has been observed. Monitoring for any signs of potential thrombosis is recommended.
The tumor marker SCC has consistently been elevated throughout the year.
In 2023Q3, radiation therapy of 2700cGy/15 was administered to the metastatic tumor in the right lower lobe (RLL). Additionally, in 2023Q2, a dose of 4500cGy/25 was directed to the anterior mediastinal tumor bed and the surrounding affected area.
The treatment regimen of paclitaxel combined with carboplatin commenced on 2023-10-31.
No discrepancies in medication were identified.
[exam findings]
[MedRec]
[consultation]
[chemoimmunotherapy]
After initiation of FOLFIRI regimen on 2024-01-12 from prior FOLFOX, both CEA as well as CA199 have dropped dramatically. Lab results other than these tumor markers were unremarkable. No drug discrepancies were noted.
2024-02-20 CEA 1531.85 ng/mL
2024-01-12 CEA 2483.63 ng/mL
2024-02-20 CA199 74.53 U/mL
2024-01-12 CA199 267.11 U/mL
Given the rising CEA and CA199 levels in recent lab results and liver metastases progression identified on the abdominal CT scan dated 2024-01-12, the treatment was switched back to FOLFIRI from FOLFOX in Jan 2024, with the addition of cetuximab starting Feb 2024.
2024-01-12 CEA 2483.63 ng/mL
2023-12-08 CEA 1122.86 ng/mL
2023-11-08 CEA 703.93 ng/mL
2023-10-04 CEA 400.12 ng/mL
2024-01-12 CA199 267.11 U/mL
2023-12-08 CA199 198.46 U/mL
2023-11-08 CA199 88.48 U/mL
2023-10-04 CA199 34.70 U/mL
Other lab parameters, including blood cell counts, electrolytes, and liver and kidney functions, remained largely normal, presenting no contraindications to the commencement of the new chemotherapy session. The patient’s back wound has been evaluated by our plastic and reconstructive surgeon, recommending an excision of the epidermal cyst under local anesthesia scheduled for the afternoon of 2024-02-07 (Wednesday). No discrepancies in medication were noted.
[tube feeding]
Potassium Supplementation Options:
Dulcolax (bisacodyl 5mg):
[tube feeding]
Const-K 750mg, an extended-release tablet, delivers 10 mEq of potassium per tablet. It is the sole oral potassium supplement available in this hospital. In comparison, a single banana provides more potassium, approximately 2.2 mEq per inch or 0.9 mEq per cm. If injectable potassium supplementation is not preferred, the Const-K tablet can be crushed into fine particles for easier swallowing with water.
Dulcolax, containing bisacodyl 5mg, is an enteric-coated formulation and should not be split or ground. As an alternative, Bisadyl supp pills, which contain bisacodyl 10mg, can be used. Currently, the patient is also taking Through (sennoside 12mg) 2# HS.
[tube feeding]
Tube feeding is available for all oral medications on the active drug list.
[reconciliation]
Based on the PharmaCloud and HIS5 documentation, there is no evidence of the patient attending any external medical facilities within the last 90 days, and within our institution, the patient’s consultations have been exclusively with the Hemato-Oncology department. A review of the patient’s medication records has not revealed any inconsistencies.
[evaluating A-FOLFIRI to A-FOLFOX switch through temporal CEA changes]
A CT scan dated 2023-10-16 showed stable disease in the sigmoid colon but indicated a mild progression of bilateral liver metastases, which aligns with the trend observed in CEA levels.
The peak CEA level within this timeline is on 2023-06-19, at 497.14 ng/mL.
After the chemotherapy regimen changed from A-FOLFIRI to A-FOLFOX on the same date (2023-06-19), the CEA levels decreased, reaching a low of 321.79 ng/mL by 2023-09-14, suggesting an initial response to the new treatment.
However, there was an increase in the CEA level to 400.12 ng/mL by 2023-10-04, which could potentially indicate a worsening condition or resistance to the current therapy.
CEA lab readings:
According to PharmaCloud and HIS5 records, the patient has no records of visits to other hospitals in the past three months, nor are there any records from departments other than Hemato-Oncology at our hospital. No medication discrepancy issues were found.
[exam findings]
[MedRec]
[immunochemotherapy]
[monitoring leukopenia in FOLFOX patient, G-CSF not used, dose reduction initiated]
The initial administration of FOLFOX occurred on 2024-01-17. Subsequently, an episode of leukopenia developed in late Jan and early Feb, with a nadir WBC count of 2.67 K/uL. No record of G-CSF administration was found in the HIS5. The patient then recovered, with a WBC count of 12.17 K/uL on 2024-02-18. As of today, no further evidence of leukopenia has been observed.
Due to the leukopenic episode, the FOLFOX dose has been reduced by approximately 20% since the second administration, which commenced on 2024-02-06.
[long-term Foliromin for iron deficiency: re-check ferritin (MCV trend down) to guide future supplementation]
The patient has a long-standing history of Foliromin (sodium ferrous citrate) prescription by our family medicine specialist for iron deficiency anemia, dating back to at least 2017.
A ferritin level of 12.1 ng/mL was measured on 2023-11-29, which falls within the lower end of the reference range. However, MCV continues to show a slowly downward trend.
2023-11-29 Ferritin 12.1 ng/mL
2024-02-18 MCV 85.4 fL
2024-02-05 MCV 87.0 fL
2024-01-30 MCV 87.9 fL
2024-01-19 MCV 86.1 fL
2024-01-09 MCV 87.5 fL
2023-11-29 MCV 89.0 fL
2023-09-06 MCV 88.6 fL
2023-06-13 MCV 94.9 fL
2022-12-19 MCV 97.7 fL
2022-09-19 MCV 96.8 fL
2022-06-25 MCV 96.9 fL
2022-03-29 MCV 97.7 fL
2022-01-05 MCV 98.1 fL
Given that previous ferritin measurements were performed approximately every 3 months, it is recommended to consider a repeat test to obtain an updated iron storage level. This will inform the decision regarding whether to re-administer iron supplements.
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
On 2024-02-19, the patient received Avastin + FOLFOX during her current hospital stay. Lab values obtained on the same date were unremarkable except for an elevated alkaline phosphatase level at 154 U/L.
A subsequent sigmoidoscopy performed on 2024-02-20 revealed luminal narrowing up to 10cm from the anal verge. This finding suggests rectal stenosis and precluded evaluation of the primary tumor site.
No medication discrepancies were identified during the review.
[lab data]
2023-07-14 Anti-HBc Reactive
2023-07-14 Anti-HBc-Value 7.77 S/CO
2023-07-14 Anti-HBs 437.04 mIU/mL
2023-07-14 HBsAg Nonreactive
2023-07-14 HBsAg (Value) 0.26 S/CO
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[uremic pruritus management in hemodialysis: potential safety concerns with levocetirizine, examining ketotifen possibility]
This hemodialysis patient reports insufficient itch relief with Allegra (fexofenadine), potentially indicating uremic pruritus. Consequently, Allegra has been replaced with Xyzal (levocetirizine).
Caution is warranted, as levocetirizine undergoes minimal metabolism (85.8% excreted unchanged). Additionally, it is nondialyzable (<10% removed during a standard 4-hour dialysis session, three times weekly). Therefore, its use is generally contraindicated in hemodialysis patients.
Even in exceptional circumstances where its use is considered, short-term administration is highly recommended to minimize drug accumulation.
One potentially safer alternative therapy to consider is ketotifen. Notably, the manufacturer’s labeling does not include specific dosage adjustments for hemodialysis patients.
Despite the lack of specific guidance, ketotifen offers several potential advantages: it undergoes extensive metabolism in humans, resulting in only three identifiable metabolites detected in urine. Additionally, reported cases of oral ingestion at up to 60 times the recommended dose did not result in fatalities. These factors suggest a potentially favorable safety profile compared to levocetirizine in this patient population.
The patient’s current medication, as listed in the active medication list, is appropriately adjusted for his hemodialysis schedule of QW135.
This patient’s PharmaCloud is currently inaccessible. After reviewing the HIS5 records, no medication reconciliation issues were identified.
Our cardiologist provided a repeat prescription for Atozet (ezetimibe, atorvastatin), Bokey (aspirin), Coxine (isosorbide-5-mononitrate), and Nebilet (nebivolol). All of these drugs are currently listed in the active medication record, and no issues with medication reconciliation have been identified.
[optimal dosage adjustment of metoclopramide for intermittent hemodialysis patients]
Metoclopramide is not effectively removed during dialysis. Therefore, it is advisable to administer approximately one-third (or less) of the standard total daily dose for patients undergoing intermittent (three times weekly) hemodialysis. ref: Metoclopramide kinetics in patients with impaired renal function and clearance by hemodialysis. Clin Pharmacol Ther. 1985;37(3):284-289. doi:10.1038/clpt.1985.41
[exam findings]
[consultation]
[chemotherapy]
2024-01-16 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr IVF
2023-12-19
2023-11-16
2023-10-18
2023-09-20
2023-08-23
2023-07-25
2023-07-04
2023-06-21
2023-05-24
2023-05-09
2023-04-25
2023-04-11
2023-03-28
2023-03-15
2023-03-07
2023-02-21
2023-02-27
2023-01-31
2023-01-10
……….
2021-12 ~ 2023-04 - Paclitaxel + Carboplatin
2021-11 ~ 2021-11 - Liposome Doxorubicin + Carboplatin
2021-09 ~ 2021-10 - Paclitaxel
2021-05 ~ 2021-09 - Paclitaxel + Carboplatin
[tube feeding]
There are 2 oral drugs - Norvasc and Alpraline included in the active medicatin list. Both of them can be tube fed.
[lab data]
2023-09-30 Anti-HBc Nonreactive
2023-09-30 Anti-HBc Value 0.08 S/CO
2023-09-30 Anti-HBs 0.17 mIU/mL
2023-09-30 HBsAg Nonreactive
2023-09-30 HBsAg Value 0.39 S/CO
2023-09-30 Anti-HCV Nonreactive
2023-09-30 Anti-HCV Value 0.08 S/CO
2023-07-03 CA125 158.1 U/mL
2023-02-15 CA125 107.4 U/mL
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[low Mg detected, MgSO4 IVD started & high glucose]
Lab on 2024-02-19 showed Mg 1.4 mg/dL, indicating hypomagnesemia, MgSO4 IVD is in use since 2024-02-20 with no discrepancy.
Blood glucose 331 mg/dL on 2024-02-20 05:07, regular insulin could be considered to mitigate the hyperglycemia.
[hypomagnesemia detected]
The eGFR has improved to 62, and cisplatin continues to be included in the treatment regimen.
On 2024-01-28, serum magnesium was measured at 1.5 mg/dL, prompting the administration of magnesium sulfate injection. Apart from hypomagnesemia, other laboratory findings and vital signs are grossly within normal limits, with no issues detected.
[declining eGFR: consider carboplatin over cisplatin]
This is the patient’s initial administration of paclitaxel alongside cisplatin. There is a potential for additive myelosuppressive effects, so it’s important to closely monitor the patient’s CBC and WBC DC for at least three weeks following the treatment.
On 2024-01-04, the patient’s eGFR of 56.41 confirmed a decrease in renal function. Given this decline trend and no contraindications, it is recommended to use carboplatin as a substitute for cisplatin.
[MedRec]
[immunochemotherapy]
[immunochemo with graded doxorubicin addition & electrolyte management]
Liposomal doxorubicin was incorporated into the existing immunochemotherapy regimen on a gradual basis. The initial dose of 20mg was administered on 2024-01-29, followed by an escalation to 40mg on 2024-02-19.
Concomitantly, Const-K and calcium carbonate were used to manage hypokalemia (3.2mmol/L) and hypocalcemia (1.99mmol/L), respectively. No medication discrepancies were identified.
[managing low platelet counts during cancer treatment]
Since Dec 2023, this patient has exhibited persistent thrombocytopenia, well before starting the R-COP regimen on 2024-01-03. While R-COP may contribute to this condition, it should not be considered the sole cause. Thrombocytopenia could also be a manifestation of the patient’s underlying DLBCL.
Patients being treated with cytotoxic chemotherapy have a suppressed bone marrow that often cannot produce adequate platelets. It is recommended to use prophylactic platelet transfusion in these settings, assuming the patient is hospitalized, afebrile, and without active infection. A threshold platelet count of 10K/uL (transfuse for a platelet count < 10K/uL) is generally used. If fever, sepsis, or coagulopathy is present, or if the patient is not hospitalized and/or cannot be closely monitored, higher thresholds may be needed. (Ref: https://www.uptodate.com/contents/platelet-transfusion-indications-ordering-and-associated-risks)
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[priority issue: bone metastases impacting gait & sensation]
It appears that the bone metastases causing lower limb weakness and numbness with difficulty walking is the most important medical problem for this patient now. Radiation oncologist has been consulted. No medication discrepancy was found.
[exam findings]
[MedRec]
[consultation]
[immunochemotherapy]
LFTs remained elevated, BaoGan is currently being used. Other labs were largely unremarkable.
No medication discrepancy found.
[high direct-to-total bilirubin ratio]
Lab data:
The ratio of direct bilirubin to total bilirubin showed an upward trend in the serial lab data. Normally, the ratio is less than 20%. A high ratio suggests a problem with the conjugation or excretion of bilirubin. Possible causes of a high ratio:
If primary biliary cholangitis is identified, the addition of Ursodiol (ursodeoxycholic acid) might be a treatment option.
[cetuximab toxicity: dose adjustment strategies]
Following the CT scan on 2023-11-10, which revealed multiple liver metastases indicating progressive disease, the treatment plan was altered from Avastin + FOLFOX to Erbitux + FOLFOX. The patient was admitted to receive the second session of the Erbitux + FOLFOX regimen.
Due to elevated levels of DBI, TBI, AST, ALT, and alkaline phosphatase, a reduced dose of the regimen was administered. Tumor markers CEA and CA199 continue to be elevated, and a significant downward trend has not been observed.
Our dermatologist has been consulted regarding the management of dermatologic toxicity and infectious sequelae associated with cetuximab, such as acneiform rash and mucocutaneous disease. The recommended approach for managing these side effects is as follows:
The refill of Baraclude (entecavir) prescribed by our gastroenterologist is included in the list of active medications with no discrepancy found.
A 28-day supply of Baraclude (entecavir) refilled on 2023-07-25 has been added as a current use item and no medication reconciliation issues found.
[liver function follow-up]
Observation shows a spike in liver enzymes, which exceeded 200 U/L in early June. Despite a visible decrease, the levels have not yet returned to the normal range. The patient is currently prescribed BaoGan (silymarin). At this time, there does not appear to be a need to change the treatment plan. Please continue to monitor the changes closely.
2023-07-26 S-GPT/ALT 97 U/L
2023-07-13 S-GPT/ALT 155 U/L
2023-07-07 S-GPT/ALT 101 U/L
2023-06-25 S-GPT/ALT 140 U/L
2023-06-21 S-GPT/ALT 156 U/L
2023-06-14 S-GPT/ALT 179 U/L
2023-06-10 S-GPT/ALT 235 U/L
2023-06-09 S-GPT/ALT 217 U/L
2023-04-26 S-GPT/ALT 27 U/L
2023-04-14 S-GPT/ALT 25 U/L
[lab data]
Examination of Bone Marrow
2023-12-15 FLT3-D835 (bone marrow) Undetectable
2023-12-15 FLT3/ITD (bone marrow) Presence of mutation
2023-12-15 NPM1 (qualitative, BM) Undetectable
2023-12-07 Anti HTLV I/II Nonreactive
2023-12-07 Anti HTLV I/II Value 0.06 S/CO
2023-12-05 Anti-HCV Nonreactive
2023-12-05 Anti-HCV Value 0.30 S/CO
2023-12-05 HBsAg Reactive
2023-12-05 HBsAg (Value) 4397.98 S/CO
[exam findings]
[chemotherapy]
[tube-feeding]
The 2 drugs in the active medication list - Anxiedin (lorazepam) and Brintellix (vortioxetine) can both be tube-fed.
[AML suppression & transfusion: prophylactic approach at 10K PLT & beyond petechiae]
Patients with AML can have suppressed bone marrow from AML and/or chemotherapy. It is generally recommended to use standard dose prophylactic transfusion of these patients at a threshold platelet count of 10K/uL, and transfusion for any bleeding greater than petechial bleeding.
[assessing anemia progression after recent LPRBC use]
The anemia observed appears to have intensified, following the administration of Leukocyte-Poor Red Blood Cells (LPRBC) on 2024-01-28. Should this condition persist, further LPRBC transfusions might be necessary.
[considering additional induction for inconsistent blast reduction]
Given that the blast count has not consistently remained below 5% (2024-01-17 bone marrow biopsy pathology IHC MPO 35-40 %) following the initial administration of the standard 7+3 regimen (2023-12-07 started) combined with Rydapt (midostaurin) for FLT3 mutation, it is advisable to proceed with a second cycle of induction therapy promptly, provided the patient’s condition allows for it.
[implementing simple suspension for esomeprazole tube feeding]
All oral medications listed as active can be administered via tube feeding. However, for Nexium (esomeprazole), it is recommended not to crush the tablets due to manufacturer guidelines. Instead, a simple suspension method (SSM) should be used to prepare the medication for tube administration.
The simple suspension method, also known as the water bath method, is a technique used to disperse solid oral medications into a liquid for administration through a nasogastric (NG) tube. This method is often used for patients who are unable to swallow tablets or capsules, such as those with dysphagia, a feeding tube, or a coma.
To perform the simple suspension method:
Tips for using the simple suspension method:
[anemia and neutropenia]
Blood product transfusion is recommended for anemia. For anticipated severe neutropenia (absolute neutrophil count [ANC] < 500 for more than 7 days), prophylactic antibiotics such as ciprofloxacin or levofloxacin may be considered as a preventive measure.
[Rydapt (midostaurin) underdosed]
On 2023-12-05, the patient tested positive for HBsAg, indicating a current infection. Baraclude (entecavir 0.5mg) has been prescribed at a dosage of 1# QDAC.
The FLT3/ITD mutation was detected on 2023-12-15. Rydapt (midostaurin) is recommended at a dosage of 50 mg twice daily from days 8 to 21 of each induction cycle, in combination with daunorubicin and cytarabine. A second induction cycle is advised if there is clear evidence of significant residual leukemia. Presently, Rydapt (midostaurin) is being administered at 25mg BID, which is half the recommended dose. It is therefore suggested to increase the dosage to the recommended 50mg BID.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma - 2024-02-19 - https://www.uptodate.com/contents/image?imageKey=ONC%2F101205
Cycle length: 28 days.
Regimen
Multiple Myeloma - VTD (IV-28)-Bortezomib (IV)-Dexamethasone-Thalidomide (28 day) - 2024-02-19 - https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Myeloma/MyelomaVTDBortezomibIVDexamethasoneThalidomideVer1.pdf
28 day cycle for up to 6 cycles
Cycle 1
Cycle 2, 3, 4, 5, 6
VTD - Bortezomib, Thalidomide & Dexamethasone - Multiple Myeloma - 2024-02-19 - https://www.clatterbridgecc.nhs.uk/application/files/3415/9679/5924/VTD__Bortezomib_Thalidomide__Dexamethasone_Multiple_Myeloma_Protocol_V1.0.pdf
Since Sep 2023, IgG levels have returned to the normal range. The patient admitted this time for peripheral blood stem cell (PBSC) collection. Lab findings from 2024-02-06 were largely within normal limits. Medication not found to be missing.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[responding to a glucose surge with insulin regulation]
A significant increase in serum glucose was observed, spiking to 310 mg/dL at 10:38 on 2024-02-19 from 166 mg/dL on 2024-02-18. Regular insulin has been administered since 2024-02-18. It may be necessary to adjust the dosage of regular insulin upward if the elevated glucose levels are not adequately controlled.
[managing benzodiazepine overdose with flumazenil]
Lab findings from the urine analysis confirmed benzodiazepine toxicity.
Flumazenil-hameln (at a concentration of 0.1 mg/ml in a 5 ml ampoule, available now in this hospital) is indicated for the treatment of benzodiazepine overdose. The initial intravenous dose is 0.2 mg administered over 2 minutes; if the desired level of consciousness is not achieved within 1 minute following the initial dose, an additional 0.2 mg may be administered at 1-minute intervals, up to a total of four times. The typical cumulative dosage ranges from 0.6 to 1 mg, with a maximum cumulative dose of 1 mg.
[more pain meds or hospice: addressing patient’s pain-driven death wish]
Based on the psychosomatic medicine consultation, the patient’s desire for death seems to stem from uncontrolled pain. Assuming this is the case, introducing additional analgesics may help alleviate the patient’s suffering. Alternatively, if the pain proves intractable, hospice palliative care may be recommended to both the patient and her family.
Currently, the patient is only being administered oral Tramacet (a combination of tramadol and acetaminophen) for pain management. To enhance analgesic efficacy, consideration could be given to the as-needed (PRN) use of morphine.
Pathological confirmation of metastatic pancreatic ductal adenocarcinoma was obtained. Lab tests on 2023-12-12 revealed elevated tumor markers CA199 (14408.29 U/mL) and CEA (363.79 ng/mL).
No further results from driver mutation testing are currently available.
Instead of FOLFIRINOX regimen, the patient was initiated on gemcitabine + nab-paclitaxel on 2023-12-21. This combination is considered to have a little more favorable safety profile compared to FOLFIRINOX (NCCN guidelines, version 2023-06-19).
The patient has a long history of type 2 diabetes mellitus. The drugs prescribed by our endocrinologist have been integrated into the active medication list, confirming no discrepancies.
[MedRec]
[surgical operation]
[tube-feeding]
Tube feeding is available for all oral medications on the active drug list.
[exam findings] (not completed)
2024-01-19 CT - chest
2024-01-12 2D transthoracic echocardiography
2024-01-10, 2023-12-11, -11-16 CXR
2023-10-26 Cell Block
2023-10-25 2D transthoracic echocardiography
……….
2019-09-03 CT - abdomen
2019-05-27 EUS
2019-05-27 CT - chest
2019-05-03 Surgical pathology Level IV
2019-04-23 CT - abdomen
[MedRec]
[consultation]
[radiotherapy]
[chemmotherapy]
[proactive potassium supplementation for heart patients on propafenone]
Laboratory findings revealed the development of hypokalemia.
Hypokalemia typically manifests with serum potassium concentrations between 3.0 and 3.4 mEq/L, often remaining asymptomatic. However, individuals with pre-existing cardiac conditions, particularly those receiving digitalis or certain antiarrhythmic medications, may experience symptoms at these potassium levels.
Therefore, potassium supplementation is recommended throughout propafenone therapy to proactively address potential hypokalemia.
Lab data from 2024-01-22 indicated that the tumor markers CEA and SCC continued their previous upward trend. Other lab parameters, such as blood cell counts, electrolytes, and liver and kidney functions, were within acceptable ranges. No discrepancies in medication were identified.
[evolving disease activity? CEA & SCC levels raise concerns]
Since mid-Dec 2023, an initial upward trend has been observed in both CEA and SCC levels. This may suggest possible disease progression or decreased effectiveness of the current treatment regimen (Erbitux + FOLFIRI, initialized early Nov 2023).
2024-01-09 CEA (NM) 4604.100 ng/ml
2023-12-26 CEA (NM) 3546.800 ng/ml
2023-12-15 CEA (NM) 3143.700 ng/ml
2023-12-01 CEA (NM) 6128.400 ng/ml
2023-11-17 CEA (NM) 15774.500 ng/ml
2023-10-20 CEA (NM) 20331.000 ng/ml
2023-10-03 CEA (NM) 29059.500 ng/ml
2023-07-11 CEA (NM) 11534.600 ng/ml
2023-06-20 CEA (NM) 5571.400 ng/ml
2023-05-16 CEA (NM) 2113.400 ng/ml
2023-03-21 CEA (NM) 194.380 ng/ml
2023-02-15 CEA (NM) 31.804 ng/ml
2024-01-09 SCC (NM) 2.64 ng/mL
2023-12-15 SCC (NM) 1.76 ng/mL
2023-12-01 SCC (NM) 1.46 ng/mL
2023-11-17 SCC (NM) 2.18 ng/mL
2023-10-20 SCC (NM) 3.31 ng/mL
2023-10-03 SCC (NM) 3.08 ng/mL
Repeat prescriptions that are still valid currently within the past 3 months are not shown in PharmaCloud.
Slight hyponatremia, hypocalcemia, and hypomagnesemia were observed in the laboratory results from 2023-11-16. Close monitoring is recommended.
An episode of leukopenia occurred on 2023-11-10, approximately 1 week after the patient’s first dose of Erbitux + FOLFIRI (reduced dose). The patient’s WBC before the second administration of the regimen was even lower than before the first administration. Therefore, there is a possibility of developing another episode of leukopenia after the second administration. Careful monitoring is advised.
[lab data]
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
As of 2024-02-16, the patient demonstrates stable vital signs and grossly normal laboratory values (2024-02-15). Entecavir (Baraclude) is currently utilized for the management of Anti-HBc positivity. No medication discrepancies were identified.
[lab data]
2023-06-19 RPR/VDRL Nonreactive
2023-06-19 HIV Ab-EIA Nonreactive
2023-06-19 Anti-HIV Value 0.05 S/CO
2023-06-19 Anti-HBs >1000.00 mIU/mL
2023-06-19 HBsAg Nonreactive
2023-06-19 HBsAg (Value) 0.30 S/CO
2023-06-19 Anti-HCV Nonreactive
2023-06-19 Anti-HCV Value 0.07 S/CO
2023-06-06 HBsAg Nonreactive
2023-06-06 HBsAg (Value) 0.27 S/CO
2023-06-06 Anti-HCV Nonreactive
2023-06-06 Anti-HCV Value 0.08 S/CO
2023-06-06 Anti-HBc Reactive
2023-06-06 Anti-HBc-Value 4.98 S/CO
2023-05-30 CEA (NM) 1908.200 ng/ml
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
RT (2024-01-26 ~ 2024-02-08): 3000cGy/10 fractions (6MV photon) of the metastatic brain tumor. RT (2024-02-05 ~ undergoing): 1500cGy/5 fractions (10MV photon) of the metastatic sacrum area.
[chemotherapy]
[reconciliation]
Treatment for the patient’s UTI commenced on 2024-02-15 with Flumarin (flumoxef sodium) 1000mg Q8H IVD. Additionally, on 2024-02-05, the patient initiated radiotherapy of the metastatic sacrum area with a total dose of 1500 cGy delivered in 5 fractions using 10MV photons. Baraclude (entecavir) is used to prevent HBV from becoming reactivated. No medication discrepancies were identified.
After examining both PharmaCloud and HIS5 records, no medication discrepancies were found.
Erbitux (cetuximab) was first administered on 2023-08-03 in conjunction with the 4th dose of the FOLFIRI regimen which began on 2023-06-27 (2023-06-09 no variant detect in the KRAS/NRAS gene). Based on the CEA lab data, the decreasing trend suggests that the regimen has been effective so far.
2023-08-23 CEA (NM) 457.140 ng/ml 2023-08-04 CEA (NM) 962.760 ng/ml 2023-07-14 CEA (NM) 1473.200 ng/ml 2023-07-14 CEA (NM) 1508.900 ng/ml 2023-05-30 CEA (NM) 1908.200 ng/ml
As of the current date, the patient’s oral Alinamin-F (vitamin B complex) and Bokey (aspirin) prescriptions, which were refilled for 30 days on 2023-07-15, are not listed in the active medication list. To ensure patient appropriate treatment, it is advisable to recheck the necessity of these medications.
According to the PharmaCloud records, the patient received treatment for acute sinusitis from a local ENT clinic on 2023-05-25 and was provided with a 3-day short-term prescription that is no longer valid. This does not pose a medication reconciliation issue.
On 2023-05-08, the patient was prescribed Evista (raloxifene 60mg) 1# QD and Celebrex (celecoxib 200mg) 1# QD by our hospital’s orthopedic department, both on a refillable basis. Currently, Evista is included in the patient’s active medication list. Celebrex has been replaced by Deflam-K (diclofenac 25mg) 1# QD, which does not seem to present any medication reconciliation issues. The adjustments are in alignment with the patient’s current health status.
A fistula between the sigmoid colon and the bladder was seen on 2023-05-25 in the lower GI series. A urine culture obtained on 2023-06-13 confirmed the presence of both Enterococcus faecalis and Escherichia coli, both greater than 100,000 CFU/cc. After a T-loop colostomy on 2023-06-15, the stool culture on 2023-06-19 showed only the presence of normal flora, with no non-intestinal pathogens identified.
The lab results from 2023-06-06 and 2023-06-19 indicated that the patient tested positive for Anti-HBc and Anti-HBs, suggesting a past HBV infection. Given this, if immunosuppressive chemotherapy is planned, prophylactic antiviral therapy with either Baraclude (entecavir 0.5mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25mg) 1# QD is recommended, at least for the duration of the chemotherapy. This measure can help prevent potential reactivation of the HBV infection due to the immunosuppressive effects of chemotherapy.
[exam findings]
[MedRec]
[consultation]
[MedRec]
[repeated leukopenia episodes after chemo, g-csf prophylaxis may be prudent]
Following the first chemotherapy session on 2023-12-26, and the second session on 2024-01-18, the patient experienced episodes of leukopenia with nadir WBC counts of 1.43 K/uL on 2024-01-02 and 2.06 K/uL on 2024-01-26. Given these observations, prophylactic G-CSF administration may be prudent.
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[gabapentin and duloxetine in neurotoxicity management]
Grade 2 neurotoxicity has been recorded in the patient’s progress notes. Neurontin (gabapentin) is currently being administered for management. Should the neurological symptoms persist, the use of duloxetine may be considered as a potential therapeutic option.
Ref: Platinum-induced neurotoxicity and preventive strategies: past, present, and future. Oncologist. 2015 Apr;20(4):411-32. doi: 10.1634/theoncologist.2014-0044. Epub 2015 Mar 12. PMID: 25765877; PMCID: PMC4391771.
[Dipeptiven administration]
To the primary nurse,
Dipeptiven 100 mL (alanyl glutamine 20g) can be diluted with NS 250-1000 mL. After dilution, it can be stored at room temperature for 24 hours.
If the patient is still on port-A, based on her body weight of about 56kg, IV infusion is recommended not less than 3.6 hours (20g / (0.1g/kg/hr x 56kg)), 4 to 6 hours would be even better.
[chemotherapy]
[leukopenia]
It appears that the patient’s WBC level has been in a downward trend even with G-CSF. G-CSF is still the appropriate agent for this patient’s leukopenia episodes.
[exam findings]
[MedRec]
[chemotherapy]
[adapting Vidaza (azacitidine) dosing in MDS treatment]
The patient, weighing 59kg with a height of 159cm, has a BMI of 23.3 kg/m2 and a BSA of 1.61 m2.
For MDS, azacitidine administration is typically recommended as follows:
Alternative dosing schedules include:
For this patient, Vidaza (azacitidine) was administered at an approximate dosage of 62 mg/m2/day (100mg/day) for 3 or 2 days, with intervals varying from 1 to 3 weeks. This represents a lower dosage (mg/kg/day), shorter duration (reduced from the recommended 7 or 5 days to 3 or 2 days), and a more frequent dosing schedule (shorter cycle intervals). Deviating from the standard recommended regimen could potentially yield different therapeutic outcomes from the original regimen’s design.
[transfusion-dependent patient: elevated ferritin suggests iron overload, deferasirox considered]
Given the patient’s history of receiving multiple blood transfusions monthly for an extended period, lab data from 2023-12-13 revealed a serum ferritin level of 2261.8 ng/mL, suggesting the possibility of iron overload. Jadenu (deferasirox), the sole iron chelator available at this institution, could be considered as a treatment option. As of 2024-02-16, the patient’s ALT level was 14 U/L and the eGFR was 60.88 ml/min/1.73m^2, indicating no contraindications for using this medication. Jadenu treatment may be initiated at a dosage of 14 mg/kg daily, with subsequent dose adjustments every 3 to 6 months, depending on serum ferritin levels.
Jadenu (deferasirox) at a daily dose of 360 mg has been administered since Dec 2023. This dosage is below the suggested level of 14 mg/kg for a 59 kg individual, which would amount to 826 mg daily.
[exam findings]
[MedRec]
[surgical operation]
[immunochemotherapy]
2024-02-15 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Opdivo + FOLFOX, Q2W. He JingLiang)
2024-01-18 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Opdivo + FOLFOX, Q2W. He JingLiang)
2024-01-03 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Opdivo + FOLFOX, Q2W. He JingLiang)
2023-12-18 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Opdivo + FOLFOX, Q2W. He JingLiang)
2023-12-01 - nivolumab 2mg/kg 100mg NS 100mL 1hr (Wu ChaoQun)
2023-11-23 - [oxaliplatin 300mg/m2 425mg + mitomycin-C 15mg/m2 21mg] IP 1hr (HIPEC. Wu ChaoQun)
[reconciliation]
An abdominal CT scan performed on 2024-02-16 demonstrated a partial response of the signet-ring cell gastric cancer to the current treatment regimen of nivolumab plus FOLFOX. Vital signs remained stable throughout this hospitalization, and lab findings on 2024-02-15 were generally within normal limits. No medication discrepancies were identified.
[nivolumab dosing recommendations for gastric cancer: optimization based on clinical research]
Clinical Evidence:
Optimizing Treatment Efficacy:
Ref: - First-line nivolumab plus chemotherapy versus chemotherapy alone for advanced gastric, gastro-oesophageal junction, and oesophageal adenocarcinoma (CheckMate 649): a randomised, open-label, phase 3 trial. Lancet. 2021 Jul 3;398(10294):27-40. doi: 10.1016/S0140-6736(21)00797-2. Epub 2021 Jun 5. PMID: 34102137; PMCID: PMC8436782).
[lab data]
[exam findings]
[MedRec]
[chemotherapy]
[navigating anemia treatment for MDS with iron overload]
Azacitidine and decitabine are commonly known as hypomethylating agents (HMA) due to their ability to inhibit DNA methyltransferase. However, it remains uncertain whether this inhibition fully explains their therapeutic action in Myelodysplastic Syndromes (MDS). Comparative studies between azacitidine and decitabine in lower-risk MDS cases have not definitively shown one HMA to be superior to the other. This patient underwent 6 sessions of Vidaza (azacitidine) treatment from Nov 2022 to May 2023, approximately on a monthly basis. For patients who do not sufficiently respond to one HMA, the likelihood of responding to the other is minimal.
Laboratory results on 2024-02-01 revealed a serum ferritin level of 1811 ng/mL, suggesting possible iron overload, likely due to repeated blood transfusions. Should this diagnosis be confirmed, Jadenu (deferasirox), the sole iron chelator available at this hospital, might be considered as a viable treatment option. However, its use is contraindicated in patients with an eGFR < 40. Given the patient’s creatinine level of 6.03 mg/dL, eGFR of 9.82 ml/min/1.73m^2, and BUN of 104 mg/dL on 2024-02-16, it is advisable to minimize the frequency of LPRBC transfusions. Moreover, treatment with erythropoiesis-stimulating agents (ESA) to alleviate anemia associated with MDS is generally more efficacious in patients with serum erythropoietin (EPO) levels below 500 mU/mL. For patients with an adequate response to ESA therapy, it is recommended to continue treatment and adjust administration to minimize transfusions and maintain HGB 10 to 12 g/dL.
The patient’s reliance on blood transfusions to maintain HGB and PLT levels is a critical aspect of his clinical history and care. The levels of both HGB and PLT have been consistently below the lower limit of normal since 2021, according to available laboratory data in HIS5. Anemia and thrombocytopenia are present prior to the initiation of azacitidine treatment, suggesting that these conditions are unlikely to be due solely to the drug. However, azacitidine may exacerbate these conditions because it can cause myelosuppression. The most update PLT level on 2023-05-09 was 21K/uL. In circumstances where the PLT count dips below 25K/uL, a dose reduction of 50% for the upcoming treatment cycle is typically recommended.
The patient’s serum creatinine level has remained below 2mg/dl until late March 2023, and there is currently an obvious upward trend in the level.
Deferasirox can cause acute renal failure and death, particularly in patients with comorbidities and those who are in the advanced stages of their hematologic disorders. Deferasirox is contraindicated in patients with eGFR less than 40mL/min/1.73m2.
Other iron chelators are available in the market, but this hospital does not procure deferiprone and deferoxamine is currently out of stock.
To prioritize kidney function over iron overload, an alternative option could be to reduce or hold the dose of deferasirox to prevent the serum creatinine from exceeding 2mg/dL. (eGFR 40 to 60 mL/minute/1.73m2: Reduce initial deferasirox dose by 50%. ref: UpToDate)
Transfusional iron overload occurs when transfusions are given for anemia not caused by iron deficiency. Despite the administration of Jadenu (deferasirox) since early December 2022, the patient’s ferritin level has been consistently fluctuating at a high level since that time.
Vidaza (azacitidine) to treat MDS: Subsequent cycles 75 mg/m2/day for 7 days every 4 weeks; dose may be increased to 100 mg/m2/day if no benefit is observed after 2 cycles and no toxicity other than nausea and vomiting have occurred. Patients should be treated for a minimum of 4 to 6 cycles; treatment may be continued as long as patient continues to benefit.
Since the patient has been admitted to receive his 4th cycle of azacitidine during this hospitalization, it would be appropriate to evaluate the effectiveness of the treatment in the next few follow-up visits.
Lab data (2022-12-23) showed low HGB (8.4g/dL, grade 3) and PLT (33K/uL, grade 3). Jadenu (deferasirox) 360mg PO DQAC is applied to lower the excess iron storage in this patient following times of LPRBC transfusion. Since September 20, 2022, Feburic (febuxostat 80mg) has been successful in lowering the patient’s serum uric acid. Rare excess ULN events have been observed since then. The recommended initial dose of febuxostat is 40 mg once daily, as the patient is senior aged, his hyperuricemia has been well-controlled, and his renal function readings are outside the normal limits, it is recommended to adjust the febuxostat dose to 40mg QD. It appears that Allegra (fexofenadine), Feburic (febuxostat), Jadenu (deferasirox), Smecta (dioctahedral smectite), Stogamet (cimetidine), Utapine (quetiapine) have been prescribed twice (one of each drug marked as a self-carried item). Please confirm the need for multiple prescriptions.
2022-11-25 albumin 3.2g/dL. The patient is receiving azacitidine for the first time. In a study, it was suggested that the use of azacitidine is not recommended when albumin levels are lower than 3 g/dL. (ref: Dose recommendations for anticancer drugs in patients with renal or hepatic impairment. Lancet Oncol. 2019;20(4):e200-e207. doi:10.1016/S1470-2045(19)30145-7). A closer monitor might be necessary.
Allogeneic hematopoietic cell transplantation (HCT) is the treatment with the highest potential to cure MDS. However, because of advanced age, comorbid conditions, lack of adequately matched donors, and/or patient preferences, only a small subset of patients with MDS are candidates for allogeneic HCT. Ferritin 694.9ng/mL (2022-08-13, normal 23.9~336.2). A high level of iron in the blood might lead to hemochromatosis. The clinical manifestations of iron overload can be influenced by the amount of tissue iron and the presence of other conditions that lead to organ dysfunction. Cardiac iron overload can lead to the following complications: dilated cardiomyopathy, diastolic dysfunction, heart failure, conduction disturbances, sinus node dysfunction. (NT-proBNP 14016 pg/mL 2022-09-28 <- 5491 pg/mL 2022-09-16) There is no further deterioration in kidney function during Sep 2022 as ceatinine remains around 1.5 mg/dL and eGFR remains around 45-50 mg/dL.
[drug identification]
requesting drug identification for 2 items.
all the 2 items are identified as following…
these drugs will be sent back to ward by an in-hospital porter.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
No instances of hyponatremia have been observed since Oct 2023. During the current hospitalization, vital signs have remained stable and lab findings on 2024-02-15 were unremarkable. No medication discrepancies were identified.
Hyponatremia is noted. The serum sodium levels in this patient over the past three months have been documented as follows:
2023-09-18 Na (Sodium) 113 mmol/L 2023-09-17 Na (Sodium) 114 mmol/L 2023-09-16 Na (Sodium) 116 mmol/L 2023-09-15 Na (Sodium) 113 mmol/L 2023-09-14 Na (Sodium) 106 mmol/L 2023-09-14 Na (Sodium) 105 mmol/L 2023-09-13 Na (Sodium) 101 mmol/L 2023-08-31 Na (Sodium) 122 mmol/L 2023-08-27 Na (Sodium) 126 mmol/L 2023-08-24 Na (Sodium) 111 mmol/L
Hyponatremia, with some cases being severe (sodium <120 mmol/L), has been associated with tramadol use. Although it is less likely that the current case of hyponatremia is due to Tramacet 0.5# Q6H, which was initiated on 2023-09-13, well after the onset of hyponatremia, it would be prudent to hold tramadol-containing medications and monitor the patient’s sodium levels for several days.
[exam findings]
[MedRec]
[chemotherapy]
Chemotherapy regimens for metastatic pancreatic cancer: FOLFIRINOX - 2024-02-16 - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571
Cycle length: 14 days.
Regimen
Modified FOLFIRINOX chemotherapy for pancreatic cancer - 2024-02-16 - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546
Cycle length: 14 days.
Regimen
[rising CA-199 in newly-started FOLFIRINOX Regimen, further investigation needed. unremarkable labs & no med discrepancies]
This patient initiated FOLFIRINOX treatment in late January 2024 and the current hospitalization pertains to the second cycle. While other lab findings on 2024-02-15 were unremarkable and no medication discrepancies were identified, ongoing elevation of the tumor marker CA-199 warrants further investigation.
[exam findings]
[MedRec]
[tube feeding]
There are currently no oral drugs on the active medication list.
[lab data]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemoimmunotherapy]
2024-01-25 - glofitamab 2.5mg NS 100mL 4hr (Columvi)
2024-01-18 - obinutuzumab 1000mg NS 500mL 5hr (Gazyva)
2023-12-07 - rituximab 375mg/m2 650mg NS 500mL 8hr D1 + carboplatin AUC 5 300mg 24hr D2 + dexamethasone 40mg/m2 20mg BID PO D2-5 + cytarabine 2000mg/m2 3500mg NS 500mL 3hr Q12H D3 (R-DHAP Q3W. Gao WeiYao)
2023-09-26 - rituximab 375mg/m2 679mg NS 500mL 8hr D1 + cisplatin 100mg/m2 180mg NS 500mL 24hr D2 + dexamethasone 40mg/m2 20mg BID PO D2-5 + cytarabine 2000mg/m2 3600mg NS 500mL 3hr Q12H D3 (R-DHAP Q3W. Gao WeiYao)
2023-06-20 (R-CHOP Q3W. Xia HeXiong)
2023-05-30 - rituximab 375mg/m2 680mg NS 500mL 10hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
2023-04-03 - rituximab 375mg/m2 680mg NS 500mL 10hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
2023-03-09 - rituximab 375mg/m2 680mg NS 500mL 10hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
2023-02-17 - rituximab 375mg/m2 680mg NS 500mL 10hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
(R)DHAP - Cisplatin, Cytarabine and Dexamethasone +/- Rituximab - 2024-01-08 - https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2018/11/RDHAP.pdf
60 - 100%
[kidney decline and fluid concern: edema check recommended]
Kidney function is deteriorating.
The patient’s body weight increased from 70.4kg on 2024-02-02 to 75.1kg on 2024-02-08. It is advisable to assess for any indicators of fluid accumulation or edema.
When furosemide is used, higher doses may be required to achieve the desired diuretic response due to decreased secretion into the tubular fluid.
Additionally, the absence of acidosis is confirmed by blood gas analysis on 2024-02-08. If the underlying causes of the acidosis have been resolved, then it would be appropriate to consider discontinuing sodium bicarbonate therapy at an opportune moment.
[strategic Jadenu administration: addressing high ferritin level]
On 2024-02-01, a ferritin level of 10238 ng/mL was observed, potentially indicative of iron overload, possibly from multiple blood transfusions. Confirmation of this could lead to the consideration of Jadenu (deferasirox) as a treatment option, the only iron chelator available in this hospital. Its use is contraindicated for patients with eGFR < 40. (2024-02-01 eGFR 19.94 ml/min/1.73m^2)
Upon recovery of kidney function to eGFR > 40, an initial 50% dose reduction is recommended. No dosage adjustment is needed for eGFR > 60.
For patients with moderate liver impairment (Child-Pugh class B), a 50% dose reduction is advised initially, with vigilant monitoring for efficacy and adverse reactions that might necessitate further dosage adjustments. Jadenu use is not recommended for severe liver impairment (Child-Pugh class C).
In cases with no liver or kidney impairments, Jadenu may be started at 14 mg/kg daily, with dose adjustments every 3 to 6 months based on serum ferritin levels, and tailored to individual responses and treatment goals. If control is insufficient at 21 mg/kg/day, doses may be increased up to 28 mg/kg/day for persistently high serum ferritin levels above 2500 ng/mL. Doses above 28 mg/kg/day are not advised. A reduction in dose is considered if serum ferritin levels drop below 1000 ng/mL on two consecutive assessments, especially for doses above 17.5 mg/kg/day. Therapy should be paused if levels fall below 500 ng/mL, with monthly monitoring thereafter.
[monitoring for CRS during these 2 or 3 days]
The last R-DHAP treatment was administered on 2023-12-07, with an expectation that the bone marrow suppression effect would almost diminish by the end of the year. However, since the beginning of 2024, the patient’s HGB levels have continued to remain low, ranging from just over 6 to 8 g/dL, indicating persistent anemia.
Gazyva (obinutuzumab) was administered on 2024-01-18, and 8 days later today 2024-01-26, the patient’s HGB had dropped by approximately 1 g/dL, necessitating a transfusion today. While the incidence of anemia with Gazyva is 12% to 39% (grades 3/4: 5% to 10%), it was administered only once as per the regimen schedule. Attention should now be directed towards the potential impact of Columvi (glofitamab) administered on 2024-01-25, as it has a higher incidence of decreased hemoglobin (72%; grades 3/4: 8%).
Close monitoring for cytokine release syndrome (CRS) is advised during these 2 or 3 days while Columvi (glofitamab) is being initiated.
For continuing the Columvi (glofitamab) regimen, the next 10mg dose should be scheduled for 2024-02-01 (C1D15).
[grading and managing CRS in glofitamab therapy]
Cytokine release syndrome (CRS) - 2024-01-26 - https://www.uptodate.com/contents/cytokine-release-syndrome-crs
In the event of cytokine release syndrome (CRS) caused by glofitamab, grading can be aligned with the NCI CTCAE v5.0 criteria.
Regardless of the underlying cause of mild CRS, it is suggested symptomatic treatment with antihistamines, antipyretics, intravenous fluids, and close monitoring. For patients with mild CRS, the balance of benefit and toxicity with symptomatic treatment is more favorable than with high dose glucocorticoids, tocilizumab, or interruption of the infusion. The goal of management is to prevent life-threatening toxicity from CRS while sustaining the antitumor effects of the immunotherapy.
For grade 3/4 CRS caused by glofitamab, administer dexamethasone 8 mg (or 5 mg/m2 if <45 kg; maximum: 8 mg) IV or PO Q8H for up to 3 days, then taper over 4 days. In addition, for patients with an inadequate response, tocilizumab (8 mg/kg IV) can be given.
[Bestnem 500mg Q6H too high for eGFR 18.47, consider 200mg Q6H or 500mg Q12H]
The eGFR level of 18.47 measured on 2024-01-15 falls within the 15-30 range for which the Sanford Guide recommends Imipenem/Cilastatin dosing of 200mg Q6H or 500mg Q12H. As the current regimen of Bestnem 500mg IVD Q6H exceeds the recommended Sanford Guide guidance, a dose adjustment to either 200mg Q6H or 500mg Q12H is recommended to potentially reduce the risk of adverse effects.
[Feburic dose modification for lower eGFR]
As of 2024-01-08, the patient’s uric acid level was 6.0mg/dL and eGFR was 19.54mL/min/1.73m².
While currently taking Feburic (febuxostat 80mg) 1# QD, this dosage exceeds the recommended limit of 40mg daily for patients with CrCl below 30mL/minute.
Therefore, a dose reduction to 0.5# QD is advisable to ensure safe and effective management.
[prioritizing kidney recovery: temporary hold on R-DHAP]
The patient’s eGFR has significantly declined over the past six months, dropping from over 80 to below 20 (as of 2024-01-08). This concerning decline occurred despite receiving only three immunochemotherapy sessions during this period:
Lab results for eGFR
It is important to note that the R-DHAP regimen is not recommended for patients with creatinine clearance (CrCl) below 30mL/min.
[tube feeding]
Concor 5mg - Utilize the Simple Suspension Method (SSM) for administration. This method requires dissolving the tablet in warm drinking water for 5-10 minutes, occasionally stirring or gently shaking the container until complete dissolution. Once dissolved, it is suitable for administration via a feeding tube. The SSM is effective for dissolving tablets and capsules in warm water, preparing them for suspension and tube feeding.
The patient has been regularly visiting a local healthcare provider primarily for the management of his hypertension. The most recent consultation was on 2023-06-06, during which the patient was prescribed bisoprolol, valsartan, atorvastatin, and febuxostat. The current active medication list includes Concor (bisoprolol), Feburic (febuxostat), Atozet (ezetimibe + atorvastatin), and Exforge (amlodipine + valsartan). So far during this hospitalization, there have been no observations of elevated blood pressure readings. No discrepancies have been identified in the medication reconciliation process.
Leukopenia was detected with the lowest WBC count dropping to 420/uL on 2023-06-10, 11 days after the last R-CHOP regimen was initiated on 2023-05-30. To address this, G-CSF (filgrastim 150ug) was administered for 3 consecutive days beginning on 2023-06-10, which led to a noticeable increase in WBC count by 2023-06-12.
Possible leukopenia-related bilateral ground-glass opacity in the lower lungs was revealed in the CXR performed on 2023-06-10, potentially indicating respiratory infections. This might also be substantiated by an elevated CRP level of 8.9mg/dL and a fever of 39.2°C recorded on the same day. Following the initiation of Cefim (cefepime 2000mg every 8 hours), the patient’s fever seems to have been managed effectively.
Recent lab results have shown that the patient’s hs-Troponin I, total bilirubin, and BUN levels have exceeded the upper limit of normal. The root causes of these elevated levels might require further investigation.
[exam findings]
[MedRec]
[immunochemotherapy]
2024-02-08 - vinorelbine 25mg/m2 48mg NS 50mL 10min + carboplatin AUC 5 450mg NS 250mL 2hr
2024-01-19 - vinorelbine 30mg/m2 55mg NS 250mL 10min + carboplatin AUC 5 450mg NS 250mL 2hr
2023-11-27 - Trodelvy (sacituzumab govitecan) 10mg/kg 180mg NS 100mL 3hr
2023-11-08 - Trodelvy (sacituzumab govitecan) 10mg/kg 180mg NS 100mL 3hr
2023-03-24 - Enhertu (trastuzumab deruxtecan) 100mg D5W 100mL 90min
2023-02-24 - Enhertu (trastuzumab deruxtecan) 100mg D5W 100mL 90min
2023-02-10 - Enhertu (trastuzumab deruxtecan) 100mg D5W 100mL 90min
2023-01-27 - Enhertu (trastuzumab deruxtecan) 100mg D5W 100mL 90min
2023-01-09 - Enhertu (trastuzumab deruxtecan) 100mg D5W 100mL 90min
2022-12-26 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min
2022-12-12 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 693mg NS 250mL 90min
2022-11-28 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min
2022-11-14 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min
2022-10-26 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min
2022-10-12 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min
2022-09-21 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min
2022-09-08 - Halaven (eribulin mesylate) 1.4mg/m2 2.3mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 678mg NS 250mL 90min
2022-08-23 - Halaven (eribulin mesylate) 1.4mg/m2 2.3mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 665mg NS 250mL 90min
2022-07-20 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min
2022-07-06 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min
2022-06-22 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min
2022-05-23 - Keytruda (pembrolizumab) 200mg NS 100mL 30min
2022-04-27 - Keytruda (pembrolizumab) 200mg NS 100mL 30min
2022-04-07 - Keytruda (pembrolizumab) 200mg NS 100mL 30min
2022-03-17 - Keytruda (pembrolizumab) 200mg NS 100mL 30min
2022-02-23 - Keytruda (pembrolizumab) 200mg NS 100mL 30min
2022-01-04 - pembrolizumab 200mg NS 100mL 30min + epirubicin 90mg/m2 154mg NS 100mL 30min + cyclophosphamide 600mg/m2 1030mg NS 500mL 1hr (Keytruda + EC(90) Q3W)
2021-12-07 - pembrolizumab 200mg NS 100mL 30min + epirubicin 90mg/m2 157mg NS 100mL 30min + cyclophosphamide 600mg/m2 1047mg NS 500mL 1hr (Keytruda + EC(90) Q3W)
2021-11-16 - pembrolizumab 200mg NS 100mL 30min + epirubicin 90mg/m2 160mg NS 100mL 30min + cyclophosphamide 600mg/m2 1060mg NS 500mL 1hr (Keytruda + EC(90) Q3W)
2021-10-26 - pembrolizumab 200mg NS 100mL 30min + epirubicin 90mg/m2 160mg NS 100mL 30min + cyclophosphamide 600mg/m2 1066mg NS 500mL 1hr (Keytruda + EC(90) Q3W)
2021-10-05 - pembrolizumab 200mg NS 100mL 30min + docetaxel 75mg/m2 135mg NS 250mL 60min + carboplatin AUC 2 450mg NS 250mL 2hr
2021-09-14 - docetaxel 75mg/m2 134mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
2021-08-24 - docetaxel 75mg/m2 135mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
2021-07-30 - docetaxel 75mg/m2 135mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
Treatment protocols for breast cancer - 2024-02-08 - https://www.uptodate.com/contents/treatment-protocols-for-breast-cancer
[precautions for chemotherapy during holidays]
The final two treatments of the vinorelbine plus carboplatin regimen occurred on 2024-01-19 and 2024-02-08, with the nadir of leukopenia and thrombocytopenia recorded on 2024-01-26, roughly one week after the initial treatment.
2024-02-07 WBC 9.93 x10^3/uL
2024-02-01 WBC 12.25 x10^3/uL
2024-01-29 WBC 1.11 x10^3/uL **
2024-01-26 WBC 0.68 x10^3/uL ***
2024-01-22 WBC 11.94 x10^3/uL
2024-01-17 WBC 13.18 x10^3/uL
2024-02-07 PLT 56 *10^3/uL **
2024-02-01 PLT 41 10^3/uL **
2024-01-29 PLT 74 *10^3/uL **
2024-01-26 PLT 12 10^3/uL **
2024-01-22 PLT 38 10^3/uL **
2024-01-17 PLT 114 10^3/uL
Following the administration of Granocyte (lenograstim), leukopenia has ceased. However, there was slight thrombocytopenia present even before the first treatment, which worsened post-medication.
On 2024-02-08, the second treatment day coinciding with the Lunar New Year holiday, the vinorelbine dose was reduced by approximately 15% compared to the first session. Despite this reduction, the risk of leukopenia and thrombocytopenia cannot be entirely dismissed, suggesting the preemptive preparation of G-CSF and platelet transfusions might be prudent.
[declining liver function: considering GaoGan (silymarin) in absence of contraindications]
Lab results showed that the patient’s liver function deteriorated in these 7 days, it might be beneficial to add BaoGan (silymarin) as a hepatoprotective agent if there is no contraindication.
2024-02-07 ALT 56 U/L
2024-02-01 ALT 31 U/L
2024-02-07 AST 87 U/L
2024-02-01 AST 44 U/L
2024-02-07 Bilirubin total 3.62 mg/dL
2024-02-01 Bilirubin total 2.33 mg/dL
2024-02-07 Bilirubin direct 2.30 mg/dL
2024-02-01 Bilirubin direct 1.36 mg/dL
[exam findings]
[MedRec]
2023-07-05 SOAP Hemato-Oncology Xia HeXiong
2023-06-14 SOAP Dermatology Zhou WeiTing
2023-06-14 SOAP Hemato-Oncology Xia HeXiong
2023-06-02 SOAP Hemato-Oncology Wan XiangLin
2023-05-05, -04-07, -03-08 SOAP Hemato-Oncology Wan XiangLin
2023-04-06 SOAP Dermatology Zhou WeiTing
2023-03-22, -03-08 SOAP Dermatology Zhou WeiTing
2023-02-07, -01-10, 2022-12-13 SOAP Hemato-Oncology Zhang ShouYi
2023-02-01 SOAP Dermatology Zhou WeiTing
2023-01-18 SOAP Dermatology Zhou WeiTing
2022-11-22 SOAP Radiation Oncology Huang JingMin
2021-08-10 ~ 2021-08-16 POMR General and Gastrointestinal Surgery Wu ChaoQun
2021-06-09 ~ 2021-06-11 POMR General and Gastrointestinal Surgery Wu ChaoQun
2021-03-30 ~ 2021-04-03 POMR General and Gastrointestinal Surgery Wu ChaoQun
2021-03-03 ~ 2021-03-05 POMR Gastroenterology Chen JianHua
2020-11-30 ~ 2020-12-03 POMR Gastroenterology Chen JianHua
2020-09-14 ~ 2020-09-16 POMR Gastroenterology Chen JianHua
2020-07-01 ~ 2020-07-03 POMR Gastroenterology Chen JianHua
2020-04-20 ~ 2020-04-22 POMR Gastroenterology Chen JianHua
[surgical operation]
[radiotherapy]
[immunochemotherapy]
[marked AFP suppression following current chemotherapy initiation]
Lab data on 2024-02-02 were generally within normal limits, with the exception of a notably elevated AFP level, which significantly deviated from the reference range.
Since initiating ramucirumab plus FOLFOX on 2023-11-01, the previously increasing trend in AFP levels has been markedly suppressed, even showing a slight decrease, indicating the continued efficacy of this treatment regimen.
Medication not found to be missing.
[MedRec]
[lab data]
2024-01-03 BM chromosome analyz
[exam findings]
[MedRec]
[NCCN guidelines on serum erythropoietin testing]
Revised international prognostic scoring system (IPSS-R) in myelodysplastic syndrome: score = 3.5 => risk grouop = intermediate
The NCCN guidelines recommend evaluating serum erythropoietin (EPO) levels to determine the necessity of recombinant human (rHu) EPO therapy.
While luspatercept is approved for anemia associated with MDS, it is currently not available at this hospital.
[MedRec]
[radiotherapy]
[chemotherapy]
2024-02-05 - oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2000mg/m2 3700mg NS 500mL 46hr + hydroxocobalamin 1mg IM (post oxalip) (FOLFOX)
2024-01-11 - oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2000mg/m2 3700mg NS 500mL 46hr + hydroxocobalamin 1mg IM (post oxalip) (FOLFOX)
2023-12-22 - oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2000mg/m2 3700mg NS 500mL 46hr + hydroxocobalamin 1mg IM D2 (post oxalip) (FOLFOX)
2023-11-28 - oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2000mg/m2 3700mg NS 500mL 46hr + hydroxocobalamin 1mg IM D2 (post oxalip) (FOLFOX)
2023-11-06 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr + hydroxocobalamin 1mg IM D2 (post oxalip) (FOLFOX)
……….
2023-09-05 - oxaliplatin 85mg/m2 160mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr + hydroxocobalamin 1mg IM (post oxalip) (FOLFOX)
2023-07-25 - [fluorouracil 400mg/m2 750mg NS 50mL 10min + leucovorin 20mg/m2 40mg NS 100mL 10min] D1-4
2023-06-27 - [fluorouracil 400mg/m2 750mg NS 50mL 10min + leucovorin 20mg/m2 40mg NS 100mL 10min] D1-4,7
[MedRec]
[consultation]
[chemotherapy]
2023-12-21 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-12-07 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 90mg D5W 250mL 1hr
2023-11-30 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-10-18 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-10-11 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-09-26 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-09-19 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-09-05 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-08-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-08-15 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 90mg D5W 250mL 1hr
2023-08-08 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-07-11 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-06-27 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-06-20 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-06-06 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-05-30 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-05-16 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
……….
2020-12-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2020-12-15 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2020-12-02 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2020-11-20 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 30mg/m2 50mg D5W 250mL 1hr
2020-10-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 30mg/m2 50mg D5W 250mL 1hr
2020-10-07 - irinotecan 80mg/m2 125mg NS 500mL 1.5hr
2020-09-18 - irinotecan 80mg/m2 125mg NS 500mL 1.5hr + temozolomide 140mg PO D1-2
[MedRec]
[optimizing basal insulin in hyperglycemia management]
Throughout this hospitalization, serum glucose levels in the TPR panel were consistently observed between 200mg/dL and 290mg/dL. It is recommended to increase the daily basal insulin dosage by 2 units to assess potential improvements in glucose management.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[hyperglycemia and leukocytosis: a cortisol connection?]
Lab results:
Since 2024-02-04, hyperglycemia was noted in the TPR panel, accompanied by a right-shifted leukocytosis with a predominance of neutrophils, as confirmed by lab results on 2024-02-05. These findings could be secondary to hypercortisolism, recorded at 41 ug/dL, necessitating further investigation to determine the underlying cause, which could include adrenocortical carcinoma or Cushing’s syndrome. Evaluation of ACTH levels could provide more information to form insights.
[hypokalemia]
The patient has had persistent hypokalemia since 2024-01-01. A single dose of 4 units of regular insulin was administered on 2023-12-31. No further insulin injections have been given since then. She has been receiving “0.298% KCl in 0.9% NaCl 500mL IVD BID” for a week. This delivers 40mEq of potassium daily, equivalent to 4 tablets of Const-K (750mg, 10mEq). Despite this, the serum potassium level remains low. Therefore, a gradual increase in the daily potassium supplementation may be necessary.
Low magnesium (1.7mg/dL on 2024-01-05) can independently cause the kidneys to waste potassium through the urine. This likely involves an increase in potassium channels that allow potassium to exit the body. Providing appropriate magnesium supplements could be helpful.
[MedRec]
[lab data]
2023-08-29 Anti-HBc Reactive
2023-08-29 Anti-HBc-Value 6.12 S/CO
2023-08-29 Anti-HBs 85.60 mIU/mL
2023-08-29 HBsAg Nonreactive
2023-08-29 HBsAg (Value) 0.35 S/CO
2023-08-29 Anti-HCV Nonreactive
2023-08-29 Anti-HCV Value 0.10 S/CO
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[no more leukopenia now, checking WBC left shifts]
A leukopenia episode was observed with a notably low WBC count of 1.82K/uL on 2024-02-02, following approximately two weeks after the last Opdivo + FLOT treatment on 2024-01-18. The timely administration of Granocyte (lenograstim) has effectively resolved the leukopenia as of the current date.
2024-02-05 Metamyelocyte 1.9 %
2024-02-05 Promyelocyte 1.0 %
2024-02-05 WBC 13.12 x10^3/uL 2024-02-05 Opdivo + FLOT
2024-02-02 WBC 1.82 x10^3/uL ***
2024-01-23 WBC 4.40 x10^3/uL
2024-01-17 WBC 3.72 x10^3/uL 2024-01-18 Opdivo + FLOT
2024-01-10 WBC 6.61 x10^3/uL
2023-12-28 WBC 15.72 x10^3/uL
2023-12-26 WBC 2.01 x10^3/uL **
2023-12-14 WBC 6.16 x10^3/uL 2023-12-14 Opdivo + FLOT
2023-11-28 WBC 2.84 x10^3/uL *
2023-11-21 WBC 4.20 x10^3/uL
2023-11-17 WBC 2.54 x10^3/uL * 2023-11-17 Opdivo + FLOT
2023-11-03 WBC 2.26 x10^3/uL ** 2023-11-03 Opdivo + FLOT
2023-11-01 WBC 2.17 x10^3/uL **
2023-10-11 WBC 3.22 x10^3/uL 2023-10-17 Opdivo + FLOT
2023-10-04 WBC 2.82 x10^3/uL *
2023-09-21 WBC 4.21 x10^3/uL 2023-09-21 Opdivo + FLOT
2023-09-01 WBC 5.35 x10^3/uL
The differential WBC count continues to exhibit a left shift, warranting an investigation to exclude the presence of an infection.
The lab data from 2023-12-14, as well as TPR readings, appear generally normal. After reviewing the PharmaCloud and HIS5 records, no discrepancies were found in the active medication list.
No discrepancy in the medication is found after a review of the PharmaCloud and HIS5 records.
[Lab data]
2023-10-05 BM Cytogenetics Lab Report
2023-08-30 Anti-HBc Nonreactive
2023-08-30 Anti-HBc-Value 0.36 S/CO
2023-08-30 Anti-HBs 14.93 mIU/mL
2023-08-30 HBsAg Nonreactive
2023-08-30 HBsAg (Value) 0.39 S/CO
2023-08-30 Anti-HCV Nonreactive
2023-08-30 Anti-HCV Value 0.10 S/CO
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
Dose-adjusted R-EPOCH – (da)-R-EPOCH: Infusional etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R) for non-Hodgkin lymphoma - 20231006 - https://www.uptodate.com/contents/image?imageKey=ONC%2F88411
Lab results from 2024-01-29 and 2024-02-01, along with vital signs readings in the TPR panel during the current hospital admission, remained predominantly normal. Examination of the HIS5 and PharmaCloud databases disclosed no medication discrepancies.
[etoposide dose increase back to standard recommended]
If no other issues or reasons for caution are identified, increasing the etoposide dose back to the standard level of 50mg/m2 (from the current 40mg/m2) is recommended.
[etoposide back to standard? clear coast, time to increase dose]
Recent lab tests (2023-12-22) show no obviously abnormalities.
While the etoposide dose has been reduced since 2023-11-23 (40mg/m2 75mg instead of the standard 50mg/m2 90mg), no adverse reactions of grade 2 or higher have been documented in the latest progress notes (2023-12-06 and current admission). In the event that absence of other concerns or contraindications, it is recommended to increase the etoposide dose back to the standard level.
The R-DA-EPOCH regimen was initiated on 2023-09-18 (cycle 1) and continued on 2023-11-01 (cycle 2). Lab values for LDH and B2 microglobulin were not particularly elevated at the time of diagnosis with DLBCL and have remained relatively stable, showing no significant changes after administration of one cycle of R-DA-EPOCH.
2023-10-27 B2-Microglobulin 2119 ng/mL
2023-08-31 B2-Microglobulin 1899 ng/mL
2023-10-26 LDH 179 U/L
2023-10-03 LDH 299 U/L
2023-09-06 LDH 200 U/L
During this hospitalization, the patient received the 2nd cycle of treatment. To date, there are no updated PET/CT imaging results following the initiation of therapy. The WBC DC in early Oct after the first cycle had shown single digit percentages of metamyelocytes, myelocytes, promyelocytes and atypical lymphocytes. However, in the most recent data from 2023-10-26, these numbers have dropped to zero.
| WBC DC | 2023-09-06 | 2023-09-18 | 2023-09-24 | 2023-09-26 | 2023-09-28 | 2023-10-03 | 2023-10-04 | 2023-10-09 |
|---|---|---|---|---|---|---|---|---|
| Band | 0.0 | 0.0 | 0.0 | 4.1 | 0.0 | 4.5 | 0.0 | 2.0 |
| Neutrophil | 73.5 | 54.5 | 57.2 | 92.9 | 80.4 | 53.9 | 66.7 | 59.4 |
| Lymphocyte | 16.7 | 34.6 | 38.3 | 2.0 | 15.7 | 22.5 | 18.2 | 24.7 |
| Monocyte | 8.1 | 7.7 | 1.0 | 1.0 | 1.9 | 6.7 | 10.1 | 9.9 |
| Eosinophil | 1.4 | 3.0 | 3.5 | 0.0 | 0.0 | 1.1 | 1.0 | 0.0 |
| Basophil | 0.3 | 0.2 | 0.0 | 0.0 | 1.0 | 0.0 | 0.0 | 0.0 |
| Metamyelocyte | 0.0 | 0.0 | 0.0 | 0.0 | 1.0 | 2.2 | 1.0 | 2.0 |
| Myelocyte | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 4.5 | 3.0 | 2.0 |
| Promyelocyte | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 2.3 | 0.0 | 0.0 |
| Atypical Lymphocyte | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 2.3 | 0.0 | 0.0 |
No drug discrepancy is detected.
No medication inconsistencies were identified in the review of both PharmaCloud and HIS5 records. Prophylactic G-CSF was prescribed after the patient’s first R-DA-EPOCH treatment on 2023-09-18, and only a brief period of leukopenia was observed.
[diagnosis] - 2023-03-21 admission note
[past history]
[allergy]
[family history]
[exam findings]
[surgical operation]
[immunochemotherapy]
[reconciliation]
No inconsistencies in medication management were found during a detailed review of both the HIS5 and PharmaCloud databases.
The patient visited a local clinic on 2023-06-13 for her primary hypertension. She was prescribed Norvasc (amlodipine 5mg) to be taken once daily. This medication is now on the patient’s active medication list as a self-carried item with no reconciliation issues identified.
During this hospital stay, the patient has experienced vomiting 3 to 4 times while on metoclopramide. If the symptom persists, it may be worth considering prescribing prochlorperazine upon discharge.
On 2023-04-06, the patient’s lab data showed normal readings except for an elevated CEA of 6.38ng/mL. It seems that the patient is tolerating the treatment well.
On 2023-03-07, the patient was observed to have neutropenia. However, there was no administration of G-CSF and no reduction of the regimen dosage. Despite this, there have been no new episodes of neutropenia observed as of the present time.
2023-03-16 WBC 6.12 x10^3/uL
2023-03-07 WBC 2.92 x10^3/uL
2023-03-02 WBC 6.36 x10^3/uL
2023-02-14 WBC 4.11 x10^3/uL
2023-03-16 Neutrophil 66.7 %
2023-03-07 Neutrophil 39.1 %
2023-03-02 Neutrophil 67.7 %
2023-02-14 Neutrophil 63.0 %
According to today’s (2023-03-23) CT results, there is a significant regression of D-colon cancer, peritoneal seeding, lymph nodes, lung, and liver metastases. These findings suggest that the Avastin + FOLFIRI regimen is still effective.
The patient’s medical history indicates that her mother had DM. However, there is no record of the patient’s HbA1c test result in HIS 5, which is a recommended test to monitor and manage diabetes.
[lab data]
2023-09-26 HBsAg (NM) Negative
2023-09-26 HBsAg Value (NM) 0.510
2023-09-26 Anti-HBc (NM) Negative
2023-09-26 Anti-HBc Value (NM) 2.500
2023-09-26 Anti-HCV (NM) Negative
2023-09-26 Anti-HCV Value (NM) 0.044
2023-09-26 Anti-HBs (NM) Negative
2023-09-26 Anti-HBs value (NM) <2.000 mIU/mL
[exam findings]
[MedRec]
[radiotherapy]
[chemotherapy]
[reconciliation]
Lab findings dated 2024-02-01 and vital sign measurements from the TPR panel during this hospitalization were generally within normal parameters. A detailed review of both the HIS5 and PharmaCloud databases revealed no inconsistencies in medication management.
[rectal cancer treatment: ongoing efficacy]
Lab results from 2024-01-17 indicated broadly normal values in blood cell counts, electrolytes, and liver and kidney functions, presenting no contraindications for proceeding with the third FOLFOX session during the current hospitalization.
Additionally, a sigmoidoscopy performed on 2024-01-04 revealed significant tumor regression in the rectal cancer post-chemoradiotherapy, suggesting that the overall treatment remains effective to date.
[reconciliation]
The patient recently received a 28-day supply of Gaslan, glimepiride, aspirin, and dipyridamole from JingMei Hospital on 2023-12-27 to manage his blood glucose and cardiovascular conditions. Apart from Gaslan, all other medications prescribed by JingMei Hospital and our urology department on 2023-12-25 have been included in the active medication list. It is recommended to verify if the patient’s gastrointestinal symptoms have improved, to determine if there is still a need for Gaslan.
Lab results on 2024-01-02 showed no contraindication for the patient to receive another session of chemotherapy in this hospital stay.
Lab data from 2023-12-19 and TPR readings, appear generally normal. After reviewing the PharmaCloud and HIS5 records, no discrepancies were found in the active medication list.
[exam findings] (not completed)
2024-01-15
2024-01-10 MRA - brain
2024-01-10 CT - brain
2024-01-03 Ascites tapping
2023-12-19 Ascites tapping
2023-12-05 Ascites tapping
2023-11-27 Body fluid cytology - asictes
2023-11-27 Ascites tapping
……….
2023-11-01 Patho - peritoneum biopsy
……….
2023-09-14 Patho - ovary
……….
[MedRec]
[consultation]
2024-01-12 Rehabilitation
2024-01-10 Neurology
2023-11-10 Dermatology
2023-11-02 Hemato-Oncology
2023-10-26 Obstetrics and Gynecology
2023-09-13 Obstetrics and Gynecology
[surgical operation]
[chemotherapy]
[evaluating Avastin’s risks: cerebral infarcts and bleeding concerns]
Avastin (bevacizumab) has been linked to venous thromboembolism (grades 3/4: 5% to 11%; 2024-01-31 D-dimer 7060 ng/mL FEU) and hemorrhage (grades >=3: <=7%; including major hemorrhage). Given that this patient recently experienced multifocal cerebral infarcts affecting the cerebellum and bilateral cerebral hemispheres in early to mid-January 2024, it is crucial to exclude the possibility that these infarcts may have been induced by the medication prior to next administration.
Additionally, recent lab data indicated rising CA125 and CA199 levels, warranting close observation and subsequent follow-up.
2024-01-30 CA125 (NM) 719.6 U/ml
2024-01-02 CA125 392.8 U/mL
2023-12-13 CA125 159.2 U/mL
2024-01-30 CA199 (NM) 1468.90 U/ml
2023-12-13 CA199 333.96 U/mL
2023-11-27 CA199 161.03 U/mL
[lab data]
2024-01-31 CMV IgM Nonreactive
2024-01-31 CMV IgM Value 0.10 Index
2024-01-31 Mycoplasma IgM Negative Index
2024-01-31 Mycoplasma IgM Value 0.5 Index
2024-01-31 BM chromosome analyz see attachment
2024-01-25 FLT3-D835 mutation (BM) Undetectable
2024-01-24 CMV viral load assay Target not detecetedIU/mL
2024-01-23 Aspergillus Ag Negative
2024-01-23 Aspergillus Ag Value 0.1 Ratio
2024-01-23 FLT3/ITD mutation (BM) Presence of mutation
2024-01-23 NPM1 mutation (qualit BM) Undetectable
2024-01-12 Anti-HCV Nonreactive
2024-01-12 Anti-HCV Value 0.12 S/CO
2024-01-12 Anti-HBc Reactive
2024-01-12 Anti-HBc-Value 6.70 S/CO
2024-01-12 Anti-HBs 463.82 mIU/mL
2024-01-12 HBsAg Nonreactive
2024-01-12 HBsAg (Value) 0.46 S/CO
[exam findings]
[MedRec]
[chemotherapy]
Chemotherapy induction regimens for acute myeloid leukemia - 2024-01-22 - https://www.uptodate.com/contents/image?imageKey=HEME%2F78251
FLT3-ITD mutations are found in 1/3 of AML cases, while FLT3-TKD mutations are found in approximately 10%. Laboratory results on 2024-01-23 showed FLT3-ITD (+), FLT3-TKD (-) and NPM1 (-). Wild-type NPM1 with FLT3-ITD (no adverse genetic lesion) is stratified as intermediate risk in the European LeukemiaNet stratification scheme. Rydapt (midostaurin) 50 mg BID is initiated on day 8 of the standard 7 + 3 schedule for 2 weeks, it follows the schedule without discrepancies.
[progress in AML following chemotherapy]
On 2024-01-15, the patient’s peripheral blood blast percentage was nearly 100%, and a bone marrow biopsy revealed AML, indicated by CD34+ (80%), CD117+ (90%), MPO+ (30%), and CD163+ (30%). No FLT3 mutation was found in the recent HIS5 records.
A reduced dose of the standard 7+3 regimen (cytarabine + daunorubicin) commenced on 2024-01-16. One week later, the peripheral blood blast percentage decreased to 72%, indicating an ongoing response.
A follow-up bone marrow examination is recommended between day 14 to 22 for further response assessment.
[exam findings] (not completed)
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[check to see if the tachycardia is transient]
Lab results from 2024-01-31 were largely within normal ranges, and vital signs from the TPR panel remained within normal limits, with the exception of tachycardia, noted as HR 113 this morning. Should the tachycardia prove to be transient, proceeding with chemotherapy administration should not be deemed contraindicated.
[reconciliation]
This patient’s PhamaCloud record shows receipt of Epine (quetiapine 200mg) on 2023-12-15 from MOHW Bali Psychiatric Center. It has now been replaced with Otzuka (aripiprazole 15mg). Notably, both medications carry boxed warnings regarding increased mortality in elderly patients with dementia-related psychosis and potential suicidal thoughts or behavior. HIS5 records showed the patient’s 2 past consultations for suicidal thoughts scores of 2 or higher in the Psychosomatic Medicine department, close monitoring of potential suicidal ideation and behavior is strongly advised.
Additionally, our Psychosomatic Medicine specialist suggested lorazepam on 2023-12-30, yet it isn’t listed in the active medication list. It is recommended a check of the need for lorazepam.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[reconciliation]
Lab results showed hypokalemia (2.8 mmol/L), hypomagnesemia (1.5 mg/dL), injectable KCl + NaCl, injectable MgSO4 were applied. Smecta (dioctahedral smectite) and loperamide were prescribed for diarrhea. No drug discrepancy identified
Elevated levels of CRP and PCT were detected.
Cefepime 2g Q8H started on 2023-12-14. The patient’s body temperature has shown a preliminary downward trend since its peak of 37.8’C on the morning of 2023-12-15.
[MedRec]
[surgical operation]
[reconciliation]
No medication discrepancy identified in Stazolin (cefazolin) 1000mg Q8H IVD and metronidazole 500mg Q6H IVD after appendectomy.
[diagnosis]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
2020-12-11 Colon cancer with single liver metastasis s/p RFA (2 sessions) using RVS
2020-01-19
2019-10-22
[radiotherapy]
[chemotherapy]
Lab results from 2024-01-30 did not reveal any significant findings that would contraindicate proceeding with a new session of the FOLFOX regimen.
The active medication list has been updated to include repeat prescriptions from our gastroenterologist (2023-12-30), cardiologist (2023-12-28), neurologist, urologist (2023-12-15), and psychosomatic physician (2023-11-15), with no discrepancies noted.
Lab results obtained on 2023-12-21 were largely unremarkable with the exception of mild anemia (HGB 9.5 g/dL). Due to this finding, the new session FOLFOX regimen has been continued on 2023-12-21.
Medications from repeat prescriptions issued by our neurologist, urologist (2023-12-15), and psychosomatic physician (2023-11-15) have been successfully integrated into the active medication list. No discrepancies were identified.
After checking the PharmaCloud database and the patient’s current medication list, it is confirmed that all medications from the refill order have been taken. No discrepancies are found.
[reconciliation]
The patient has attended multiple departments in our hospital and has been issued several repeat prescriptions that remain valid to date:
2023-09-19 Gastroenterology: Ulstop (famotidine), Gaslan (dimethylpolysiloxane), Mopride (mosapride citrate)
2023-09-15 Cardiology: Januvia (sitagliptin), Eliquis (apixaban), Zandip (lercanidipine)
2023-09-08 Urology: Urief (silodosin), Betmiga (mirabegron)
2023-09-01 Neurology: Muaction (tramadol), Kentamin (Vit B1, B6, B12), Trynol (amitriptyline), Neurontin (gabapentin), CaCO3, U-Ca (calcitriol)
2023-08-30 Psychosomatic Medicine: Alpraline (alprazolam)
All these medications are actively being used by the patient, and no inconsistencies have been identified.
[tumor markers]
The most recent CT scan of the abdomen dated 2023-06-30 shows no evidence of tumor recurrence in the rectum following LAR surgery. While a lesion in S5 of the liver post-RFA indicates complete recovery, a previously detected lesion in S8 and some liver cysts in the left lobe remain stable, suggesting the need for continued surveillance. However, given the increasing trend of the tumor markers CEA and CA199 in recent months, further imaging or testing may be required to obtain an updated status of the disease.
2023-09-28 CEA (NM) 41.773 ng/ml 2023-08-29 CEA (NM) 41.022 ng/ml 2023-08-01 CEA (NM) 28.657 ng/ml 2023-06-27 CEA (NM) 32.370 ng/ml 2023-06-06 CEA (NM) 38.089 ng/ml 2023-05-09 CEA (NM) 29.020 ng/ml 2023-04-11 CEA (NM) 29.090 ng/ml 2023-03-07 CEA (NM) 30.892 ng/ml 2023-02-22 CEA (NM) 22.304 ng/ml 2023-01-20 CEA (NM) 29.331 ng/ml
2023-09-28 CA-199 (NM) 128.119 U/ml 2023-08-29 CA-199 (NM) 124.920 U/ml 2023-08-01 CA-199 (NM) 100.17 U/ml 2023-06-27 CA-199 (NM) 102.499 U/ml 2023-06-06 CA-199 (NM) 108.696 U/ml 2023-05-09 CA-199 (NM) 99.780 U/ml 2023-04-11 CA-199 (NM) 94.910 U/ml 2023-03-07 CA-199 (NM) 91.315 U/ml 2023-02-22 CA-199 (NM) 66.824 U/ml 2023-01-20 CA-199 (NM) 70.223 U/ml
On 2023-06-23, our cardiologist prescribed Januvia (sitagliptin), Eliquis (apixaban), and Zandip (lercanidipine) for the patient, while on 2023-07-01, our gastroenterologist prescribed Ulstop (famotidine), Gaslan (dimethylpolysiloxane), and Mopride (mosapride citrate). All medications, with the exception of Mopride, are currently on the active medication list. Please determine if the use of Mopride is still necessary.
This patient just refilled his prescription for Januvia (sitagliptin), Eliquis (apixaban), Zanidip (lercanidipine), Betmiga (mirabegron), Urief (silodosin) on 2023-07-11 at a local pharmacy and these drugs are now added to the active medication list with no reconciliation issues found.
A review of PharmaCloud records did not identify any medication reconciliation issues.
This patient’s chemotherapy-induced polyneuropathy may be more likely due to the oxaliplatin component of the FOLFOX regimen, which was started in Oct 2021. Appropriate measures have been taken, including the addition of Kentamin (B1, B6, B12) and Neurontin (gabapentin) to the patient’s active medication regimen as prescribed by our neurologist.
The patient’s CEA and CA199 levels have shown similar upward trends in recent months, which may indicate that the disease is becoming more resistant to current treatment. This may require further evaluation and possible adjustments to the future treatment plan.
[exam findings]
[MedRec]
[consultation]
[immunochemotherapy]
[adjusting chemotherapy for hemodialysis patients: fluorouracil and irinotecan]
Fluorouracil itself is not significantly removed by dialysis, but its metabolite, FBAL, can be, making no dosage adjustment necessary for patients on intermittent hemodialysis. Administration should occur post-dialysis on treatment days.
Irinotecan, with partial dialyzability and its active metabolite SN38 not dialyzable, is advised against in hemodialysis due to potential toxicity, especially in end-stage kidney disease. If used, initializing a reduced dose of 50% to 66% of the standard, is recommended, considering individual patient response.
No medication discrepancies were noted. As of 2023-09-21, the doses of irinotecan and fluorouracil in the FOLFIRI regimen have been increased to 70% of the standard dose, and it appears that the patient is still able to tolerate them.
[hemodialysis]
Hemodialysis QW135 is arranged for the patient during the course of hospitalization on 2023-08-01 by our nephrologist and EPO 5000 IU QW is suggested if Hb < 11.
It is advisable to administer Vemlidy (tenofovir alafenamide) and famotidine after the dialysis session has been completed.
[hypertension]
Despite the patient’s current medication regimen of beta-blocker carvedilol and calcium channel blocker amlodipine, the hypertension readings remain elevated. Therefore, it may be worth considering the addition of an angiotensin-receptor blocker, such as valsartan, to better manage the patient’s hypertension.
The patient is currently taking Vemlidy (tenofovir alafenamide 25mg) once daily for his HBV condition. For patients undergoing intermittent hemodialysis (thrice weekly), Vemlidy does not require dosage adjustment. If the dose is scheduled on a dialysis day, it should be administered after the dialysis.
If the treatment is switched to Baraclude (entecavir), dosage adjustments are needed for patients on intermittent hemodialysis (thrice weekly). Although entecavir is not significantly dialyzed (13%), it is recommended to administer 10% of the usual indication-specific dose daily. Alternatively, the usual indication-specific dose can be administered every 7 days. Similar to Vemlidy, if the dose falls on a dialysis day, it should be administered after hemodialysis.
There appears to be no issue with the current anti-HBV medication listed in the active prescription for the patient.
For patients on intermittent hemodialysis (thrice weekly), the dosage adjustments for famotidine are as follows: If the usual dose is 10 mg twice daily, use 10 mg every other day; if the usual dose is 20 mg once daily, use 10 mg every other day; and if the usual dose is 20 mg twice daily, use 10 mg once daily or 20 mg every other day. No supplemental dose is necessary, and it should be administered after hemodialysis on dialysis days.
The current prescription of Ulstop (famotidine) at 10mg QD appears to be appropriate and doesn’t pose any issues.
According to the PharmaCloud database, it appears that the patient regularly visits a local physician (LMD) to refill his prescription for epoetin beta for anemia associated with end-stage renal disease (ESRD). However, this medication is not currently on the patient’s active medication list in our records. Therefore, it would be prudent to verify the patient’s continued use of epoetin beta and consider adding it to the active medication list to ensure proper medication reconciliation.
It is about to apply the FOLFIRI plus Avastin to the patient on hemodialysis.
Fluorouracil is typically administered at a standard dose to patients undergoing hemodialysis without the need for dose adjustment. However, it is generally given after the hemodialysis session on dialysis days to prevent potential drug removal during the procedure.
This patient also has coronary artery disease 3-vessel disease status post coronary artery bypass graft on 2021-10-29. Fluorouracil has been associated with cardiotoxicity, as reported in postmarketing studies. Manifestations of cardiotoxicity may include angina, myocardial infarction/ischemia, arrhythmia, and heart failure. The risk factors for this toxicity include continuous infusion administration (as opposed to intravenous bolus) and pre-existing coronary artery disease. The American Heart Association recognizes fluorouracil as an agent that may cause reversible direct myocardial toxicity or exacerbate underlying myocardial dysfunction. Therefore, if a patient has previously experienced cardiotoxicity related to fluorouracil, the risks of resuming treatment with this drug have not been well established and must be carefully weighed against the potential benefits. Given these risks, it is recommended to monitor the patient’s cardiovascular status closely during the course of treatment with fluorouracil.
As with bevacizumab, no dose adjustment is required for any degree of renal impairment. However, cardiovascular toxicity, GI toxicity (perforation or fistula), thromboembolic events should be observed.
[exam findings]
[MedRec]
[reconciliation]
The patient presented to our emergency department with a week-long history of abdominal distension and pain. CT imaging revealed multiple hepatic tumors and bone mets, necessitating further investigation to determine the primary source. Lab tests highlighted abnormalities in liver function.
Ongoing management includes hydration, analgesics, electrolyte supplementation, diuretics, and gastrointestinal motility-enhancing agents. A review of the PharmaCloud database found no discrepancies in medication administration.
[exam findings]
2024-01-18 CT - abdomen
2023-11-03 All-RAS + BRAF mutation
2023-10-04 CT - abdomen
2023-06-26 CT - abdomen
2023-06-26 CXR
2023-06-26 ECG
2023-05-31 CT - abdomen
2023-05-24 Peripheral Echography
2023-05-24 2D transthoracic echocardiography
2023-04-07, -02-23 CXR
2023-02-23 CT - abdomen
2023-01-27 Colonoscopy
2023-01-27 Esophagogastroduodenoscopy, EGD
2022-11-14 CT - abdomen
2022-10-12 Carotid angiography bilat. Vertebral angiography
2022-10-12 Aortography - thoracic
2022-10-11 ECG
2022-09-20 MRA - brain
2022-07-25 CT - chest
2022-06-27 2D transthoracic echocardiography
2022-06-21 CTA - chest
2022-06-21 Vein Sonography
2022-06-21 2D transthoracic echocardiography
2022-06-17 Patho - soft tissue tumor, extensive resection
……
2021-02-18 Patho - colon segmental resection for tumor
[consultation]
[surgical operation]
[chemotherapy]
[propranolol dosage consideration following new BP data]
Lab data from 2024-01-29 and vital signs from the TPR panel appear largely within normal limits. However, the BP reading on the morning of 2024-01-30 was 98/51 mmHg, which is not considered high. Based on the clinical context, it might be feasible to slightly reduce the dosage of Propranolol (Propranolol) if deemed appropriate.
[leukopenia]
The temporal changes in the WBC count are summarized in the following table, where records marked with an asterisk represent WBC counts < 3K/uL.
The dosage of irinotecan used on 2023-06-20 was adjusted down from the standard 180mg/m2 to 160mg/m2.
On 2023-07-03, the ANC was 2.81K/uL x 41.9% = 1177/uL, which is a grade 2 neutropenia (1000~1499/uL). If this value occurs during a therapy cycle, a further decrease of 20mg/m2 to 140mg/m2 could be considered.
[exam findings]
[MedRec]
[consultation]
[immunochemotherapy]
[lab data]
2024-01-22 HBV DNA PCR (Quantitative) 246 IU/mL
2024-01-20 HBeAg Nonreactive 2024-01-20 HBeAg Value 0.361 S/CO
2024-01-11 HBsAg (NM) Positive 2024-01-11 HBsAg Value (NM) 1660.000 2024-01-11 Anti-HCV (NM) Positive 2024-01-11 Anti-HCV Value (NM) 57.800 2024-01-11 Anti-HBc (NM) Positive 2024-01-11 Anti-HBc Value (NM) 0.007 2024-01-11 Anti-HBs (NM) Negative 2024-01-11 Anti-HBs value (NM) <2.000 mIU/mL
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[prophylactic nucleoside analogues prescribed for this HBV carrier, silymarin may also be considered.]
The presence of detectable HBV DNA PCR, positive HBsAg, and anti-HBc positivity in recent lab results warrants consideration of pre-emptive antiviral nucleoside analog therapy before commencing chemotherapy to mitigate the risk of HBV reactivation. Self-carried Vemlidy (tenofovir alafenamide) has been prescribed with no discrepancy identified.
Since elevated AST, ALT and direct bilirubin were also noted, the addition of BaoGan (silimarin) could be considered optionally if no contraindication exists.
[lab data]
2024-01-02 Anti-HBc (NM) Positive
2024-01-02 Anti-HBc Value (NM) 0.012
2024-01-02 Anti-HBs (NM) Positive
2024-01-02 Anti-HBs Value (NM) 12.6 mIU/mL
2024-01-02 HBsAg (NM) Negative
2024-01-02 HBsAg Value (NM) 0.477
2024-01-02 Anti-HCV (NM) Negative
2024-01-02 Anti-HCV Value (NM) 0.035
2023-12-27 Fe (Iron-bound) 36 ug/dL
2023-12-27 TIBC 276 ug/dL
2023-12-27 UIBC 240 ug/dL
[MedRec]
[chemotherapy]
{donor}
[MedRec]
{bone marrow donor}
[MedRec]
2024-01-30
2024-01-23 SOAP Hemato-Oncology He JingLiang
[exam findings] (not completed)
[MedRec]
2023-12-13 ~ 2023-12-18 POMR Gastroenterology Chen JiangHua
2023-10-20 ~ 2023-10-26 POMR Gastroenterology Chen JiangHua
2023-05-15 ~ 2023-05-17 POMR Gastroenterology Chen JiangHua
2023-04-05 ~ 2023-04-08 POMR Gastroenterology Chen JiangHua
2022-12-21 SOAP Psychosomatic Medicine Chen YiQian
2022-11-08 ~ 2022-11-21 POMR Gastroenterology Chen JiangHua
2022-09-23 ~ 2022-09-27 POMR Integrative Medicine Chen HengXiang
2021-08-27 ~ 2021-08-28 POMR Nephrology Hong SiQun
2020-11-02 ~ 2020-11-10 POMR Ear Nose Throat Su WanYu
2019-06-05 SOAP Urology Xie ZhengXing
2017-08-14 SOAP Cardiology Zhang HengJia
2017-07-27 SOAP Chest Medicine Huang JunYao
2017-06-12 SOAP Metabolism and Endocrinology Yu LiJiao
[surgical operation]
[addressing continuous high glucose readings]
During this hospital stay, 4 serum glucose measurements consistently showed values around 300 mg/dL despite the administration of regular insulin and oral antihyperglycemic agents. If hyperglycemia persists, consideration may be given to adding basal insulin to the regimen.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[reconciliation]
Medications prescribed by specialists in family medicine and gastroenterology on 2024-01-26, and by cardiologists and psychosomatic medicine experts on 2024-01-16, are generally listed in the current active medication roster without issues noted.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[Bard]
Missing the loading dose of Pertuzumab (840mg) and instead using a 420mg dose requires careful consideration, as its impact on treatment efficacy and potential risks depends on several factors:
Early in the treatment course: Missing the loading dose early on can significantly impact initial drug exposure and potentially weaken treatment efficacy. In this case, resuming with the recommended maintenance dose (420mg every 3 weeks) might not be sufficient to compensate. Later in the treatment course: If several loading doses have already been administered, the impact of missing one dose might be less significant, offering more leeway for resuming with the maintenance dose.
Accidental: If the omission was accidental and unlikely to occur again, resuming with the maintenance dose may be acceptable after discussing it with your doctor.
[cGPT]
Missing the full loading dose of 840 mg and instead using a 420 mg dose could have implications for the effectiveness of the treatment, especially in the initial stages. Here are some potential considerations and impacts:
Reduced Initial Drug Levels:
The purpose of the loading dose is to quickly achieve effective drug levels in the body. Using only half of the intended loading dose may result in lower drug concentrations initially, which might reduce the effectiveness of the treatment during the early phase. Delayed Therapeutic Effect:
It might take longer to reach the therapeutic levels of pertuzumab in the bloodstream, potentially delaying the onset of the drug’s therapeutic effects. Adjustment of Subsequent Doses:
If the loading dose is missed or reduced, healthcare providers might need to adjust subsequent doses to achieve the desired drug levels. This could involve administering an additional dose or modifying the maintenance doses, though such adjustments should be based on clinical judgment and the specific circumstances of the treatment.
Clinical Decision and Monitoring:
In cases where the loading dose is not administered as recommended, it’s important for healthcare providers to closely monitor the patient’s response to treatment and adjust the dosing regimen as necessary. This might include more frequent assessments of tumor response and monitoring for side effects.
{serous carcinoma of right fallopian tube with peritoneal and pleural invastion with tumor recurrent, pT3cN1aM1a, stage IVA}
[diagnosis] - 2023-03-30 discharge note
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[surgical operation]
[chemoimmunotherapy]
Primary Systemic Therapy Regimens - Primary Therapy for Stage II–IV Disease - Epithelial Ovarian/Fallopian Tube/Primary Peritoneal (Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer, NCCN guidelines version 5.2022 20220916, OV-C 6 OF 11, p43)
Acceptable Recurrence Therapies for Epithelial Ovarian (including LCOC)/Fallopian Tube/Primary Peritoneal Cancer (Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer, NCCN guidelines version 5.2022 20220916, OV-C 9 OF 11, p51)
[reconciliation]
Baraclude (entecavir), Stilnox (zolpidem), and Alpraline (alprazolam) were prescribed on 2024-01-17, while Norvasc (amlodipine), Exforge (amlodipine, valsartan), and Carvedilol were prescribed on 2023-12-20 by our OPD. These medications are currently being used without any noted issues.
The patient obtained repeat prescriptions for Exforge (amlodipine, valsartan) and Hexal (carvedilol) from our cardiologist, and Lexapro (escitalopram) and Alpraline (alprazolam) from our psychiatrist on 2023-09-27. These medications are accurately listed as the patient’s active medication, and no issues with medication reconciliation have been detected.
This patient received repeat prescriptions from our cardiologist (for Exforge (amlodipine, valsartan) and Hexal (carvedilol)) and our psychiatrist (for Anxiedin (lorazepam), Lexapro (escitalopram), Stilnox (zolpidem), and Alpraline (alprazolam)) on 2023-07-05. These drugs are well included in the active formulary and no reconciliation issues were identified.
On 2023-07-08, the patient refilled her prescription for Baraclude (entecavir) at a local pharmacy. In addition, on 2023-07-05, our cardiologist wrote a prescription for Exforge (amlodipine, valsartan) and Carvedilol. On the same day, our psychosomatic medicine specialist also prescribed Anxiedin (lorazepam), Lexapro (escitalopram), Stilnox (zolpidem), and Alpraline (alprazolam) for the patient. These medications were appropriately added to the patient’s active medication list with no reconciliation issues identified.
[exam findings]
[MedRec]
[chemotherapy]
Initial treatment of peripheral T cell lymphoma - INDUCTION THERAPY - 2023-11-24 - https://www.uptodate.com/contents/initial-treatment-of-peripheral-t-cell-lymphoma
[reconciliation]
Lab results on 2024-01-25 indicated normal liver and kidney function tests, with serum uric acid levels at 9.0 mg/dL, suggesting hyperuricemia. This condition is being managed with Feburic (febuxostat), and there are no discrepancies in medication.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
2024-01-26 - docetaxel 75mg/m2 115mg NS 250mL 1hr
2023-12-25 - cetuximab 500mg/m2 700mg 1.5hr
2023-11-16 - cetuximab 500mg/m2 700mg 1.5hr
2023-10-23 - cetuximab 500mg/m2 700mg 1.5hr
2023-10-06 - cetuximab 500mg/m2 700mg 1.5hr
2023-09-04 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)
2023-07-31 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)
2023-07-03 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)
2023-06-05 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)
2023-05-08 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)
2023-04-03 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)
2022-04-26 - (cisplatin, QW)
2022-04-19
2022-04-12
2022-04-08
2022-03-29
2022-03-22
2020-10-20 - (cisplatin, QW)
2020-10-13
2020-10-06
2020-09-29
2020-09-22
2020-09-15
[neurological follow-up in this cisplatin-treated patient]
This is a patient who has a long history of underlying neurological conditions. Cervical polyradiculopathy was found on 2010-06-30. On 2010-07-23, the patient was diagnosed with herniated intervertebral discs (HIVD) at the C3, C4, C5, C6, and C7 levels, along with canal stenosis. He subsequently underwent Anterior Cervical Discectomy and Fusion (ACDF) and right Trans-Ulnar Synovectomy (TUS) / Carpal Tunnel Syndrome (CTS) neurolysis on 2010-07-07. On 2016-02-06, the patient presented with a mass on the left dorsal ear and was undergoing follow-up after cervical surgery. He also exhibited muscular atrophy in his limbs. On 2016-03-04, the patient reported soreness, especially in cold weather conditions. Later, on 2023-03-07, the patient experienced pain in the back of the neck and radiating numbness and weakness in the right upper extremity, persisting for three months. The pain was not relieved by painkillers.
The patient had used cisplatin in Sep and Oct in 2020, Mar and Apr in 2022, 2nd and 3rd quarters in 2023. Cisplatin is known associated with peripheral neuropathy.
While the patient’s neurological issues cannot be solely attributed to cisplatin, its potential role in causing neuropathy cannot be excluded. The patient has been more frequently visiting neurology since Sep 2023, with the most recent appointment on 2024-01-10. Monitoring the effectiveness of symptom control proposed by our neurologist is suggested.
Additionally, docetaxel, started during this hospitalization, is also associated with neurological adverse reactions. These include central nervous system toxicity (20% to 58%; dysesthesia and paresthesia both ≤6%), neuromuscular and skeletal issues like asthenia (53% to 66%; severe weakness 13% to 18%), myalgia (3% to 23%; severe myalgia 2%), and neuromuscular reactions (16%), as well as peripheral motor neuropathy (4%; mainly distal extremity weakness) and arthralgia (3% to 9%).
Given that chemotherapy-induced peripheral neuropathy remains a challenging medical issue to fully overcome, continued follow-up in neurology outpatient clinics is recommended.
The patient just refilled Ultracet (tramadol, acetaminophen) and Lyrica (pregabalin) for his aalignant neoplasm of hypopharynx at a local pharmacy on 2023-07-27. In current active medication list, there were Tramacet, Lyrica and Durogesic (fentanyl) prescribed, no reconciliation issues identified.
[exam findings] (not completed)
[chemotherapy]
[lab data]
2023-12-22 HBV-DNA-PCR Target Not Detected IU/mL
2023-12-21 Anti-HCV Nonreactive
2023-12-21 Anti-HCV Value 0.15 S/CO
2023-12-21 HBsAg Nonreactive
2023-12-21 HBsAg (Value) 0.49 S/CO
2023-12-21 Anti-HBs 267.16 mIU/mL
2023-12-21 Anti-HBc IgM Nonreactive
2023-12-21 Anti-HBc IgM Value 0.09 S/CO
2023-12-21 Anti-HBc Reactive
2023-12-21 Anti-HBc-Value 6.93 S/CO
[exam findings]
[MedRec]
[chemotherapy]
[alectinib administration via tube feeding]
The administration of Alecensa (alectinib) typically involves swallowing the capsule whole, as indicated in the Taiwan package insert, which advises against opening the capsule or dissolving its contents.
Despite this, there have been clinical cases where Alecensa was administered via tube feeding in patients with NSCLC, leading to positive outcomes. For instances:
Pharmacologically, alectinib hydrochloride is a white to off-white powder containing insoluble particles, formulated into immediate-release capsules. Opening the capsules may lead to dispersion and inhalation of the contents, potentially altering the active ingredient’s concentration. Laboratory tests have shown that Alecensa capsules can dissolve in 40’C warm water within 10 minutes utilizing Simple Suspension Method (SSM), although the resulting suspension may appear cloudy, making it difficult to ascertain complete dissolution. This suspension remains stable for up to 6 hours at 25’C but may turn gel-like after 24 hours. [5]
A Phase I clinical trial assessed the relative bioavailability and pharmacokinetics of an oral suspension of Alecensa compared to its capsule formulation in healthy participants. The study found higher individual peak levels and overall systemic exposure to Alecensa and its metabolite M4 in the oral suspension group, both under fed and fasting conditions, compared to the capsule group. The bioavailability of Alecensa and M4 significantly increased post-administration in the oral suspension group, but there was no significant difference in the incidence or severity of treatment-emergent adverse events (TEAEs) between the two formulations. [6]
Ref: 1. Watanabe Y et al., Ann. Cancer Res. Ther. 2016; 24:47-51. https://www.jstage.jst.go.jp/article/acrt/24/2/24_47/_article 2. Kanai O et al., Clin. Case Rep. 2017; 26:927-930. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5458002/ 3. Bejarano MT et al., J Oncol Pharm Pract 2019;25:1722-1725. https://pubmed.ncbi.nlm.nih.gov/30124125/ 4. Anderson BE et al., J Oncol Pharm Pract 2020. https://journals.sagepub.com/doi/abs/10.1177/1078155220918644 5. Manufacturer inhouse data 6. Liu S et al., Clin Transl Sci 2023;16:1085-1096. https://pubmed.ncbi.nlm.nih.gov/36978270/
[analyzing post-granocyte WBC recovery and left-shifted distribution]
Following the administration of Granocyte (lenograstim), the episode of leukopenia observed on 2024-01-22 resolved.
Subsequent lab results showed no further evidence of leukopenia and indicated a left-shifted distribution, consistent with ongoing G-CSF effect. The blood cell differential on 2024-01-25 revealed increased band cells, neutrophils, and metamyelocytes, alongside mild elevated WBC counts.
This left shift, often linked to rapid blood cell production in response to infections or inflammation, coincides with the CXR on 2024-01-22 showing patchy density in the left pulmonary hilar region. The current empirical use of Brosym (cefoperazone, sulbactam) aligns with these indications.
[ALK rearrangement discovered: targeted therapy options]
For this patient, who tested positive for ALK on immunohistochemistry IHC on 2023-12-25, consideration might be given to using alectinib, brigatinib, or lorlatinib. If alectinib is the chosen medication, the recommended dosage is 600mg taken twice daily with food.
[hypokalemia - serial serum potassium monitoring and intervention]
The serial data of serum potassium levels indicate a continuing development of hypokalemia. Consequently, Const-K 10mEq TID has been recently initiated to address this condition.
When increased sympathetic tone is thought to play a major role, the administration of a nonspecific beta blocker, such as propranolol, might be considered.
[carboplatin, pemetrexed, pembrolizumab as NSCLC treatment]
For this patient, tests have not detected EGFR or ROS1 mutations, and the PD-L1 22C3 Tumor Proportion Score (TPS) is less than 1%, with Immunohistochemistry (IHC) Tumor Cells (TC) at 5%.
If the patient recovers to ECOG PS 0-1, a potential treatment regimen could include a combination of either carboplatin or cisplatin, along with pemetrexed and pembrolizumab.
[exam findings]
[MedRec]
[stable vitals amidst possible treatment-related hematologic effects]
The patient, currently treated with fulvestrant, letrozole, and ribociclib for her infiltrating ductal carcinoma, exhibited largely normal lab values on 2024-01-25, except for leukopenia (2.1K/uL) and anemia (HGB 10g/dL). These conditions might be associated with her treatment, particularly ribociclib (anemia: 17% to 19%; leukopenia: 27% to 33%) and/or fulvestrant (anemia: 4% to 40%; lymphocytopenia: 35%).
Throughout this hospitalization, the patient’s vital signs have remained stable, and no discrepancies in medication have been identified.
[exam findings]
[MedRec]
[lab data]
2024-01-25 HBsAg Nonreactive
2024-01-25 HBsAg (Value) 0.44 S/CO
2024-01-25 Anti-HBc Nonreactive
2024-01-25 Anti-HBc-Value 0.17 S/CO
2024-01-25 Anti-HCV Nonreactive
2024-01-25 Anti-HCV Value 0.09 S/CO
[exam findings]
[MedRec]
[vaccine recommendations for hepatitis B susceptible individuals with cancer]
Lab results on 2024-01-25 show both HBsAg and anti-HBc as nonreactive. This could indicate either susceptibility to future hepatitis B infection (if anti-HBs is nonreactive) or immunity from hepatitis B vaccination (if anti-HBs is also nonreactive).
For susceptible individuals, it is recommended all unvaccinated patients with cancer aged 19 or older should receive the hepatitis B vaccine. (Ref: Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2024. MMWR Morb Mortal Wkly Rep. 2024 Jan 11;73(1):11-15. doi: 10.15585/mmwr.mm7301a3.) Additionally, coadministration of hepatitis B and hepatitis A vaccines is an option.
Inactivated vaccines are generally advised to be administered at least two weeks prior to starting chemotherapy or other immunosuppressive therapies to enhance the immune response. (Ref: Practical review of immunizations in adult patients with cancer. Hum Vaccin Immunother. 2015;11(11):2606-14. doi: 10.1080/21645515.2015.1062189.) A recombinant hepatitis B vaccine is available at this hospital.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[MedRec]
[consultation]
[ongoing renal deterioration and bumetanide dosage considerations]
Recent test results indicate a mild increase in hs-Troponin I at 164.1 pg/mL, CKMB at 17.6 ng/mL, CK at 405 U/L, and ECG showing T wave depression in lateral leads, therefore a consultation with our cardiologist is just initialized.
This patient has experienced a gradual deterioration in kidney function in recent months. Consequently, all medication dosages on the active list have been adjusted to accommodate the patient’s current renal status.
Additionally, for the patient’s eGFR <30, increased doses of bumetanide may be necessary for an effective diuretic response (2024-01-24 input 1710 output 230 + loss).
Given the absence of serological hepatitis virus data in the patient’s history in HIS5, the elevated liver enzyme levels (AST at 170 U/L and ALT at 95 U/L on 2024-01-25) might be further investigated once the patient’s cardiological conditions have stabilized.
[exam findingns]
2024-01-25 HBsAg Nonreactive
2024-01-25 HBsAg (Value) 0.42 S/CO
2024-01-25 Anti-HCV Nonreactive
2024-01-25 Anti-HCV Value 0.14 S/CO
2024-01-25 Anti-HBc Reactive
2024-01-25 Anti-HBc-Value 3.19 S/CO
2024-01-25 Anti-HBc IgM Nonreactive
2024-01-25 Anti-HBc IgM Value 0.08 S/CO
2024-01-25 Anti-HBs 184.65 mIU/mL
[MedRec]
[reactive anti-HBc and prophylactic antiviral strategy]
Lab results on 2024-01-25 indicated a reactive anti-HBc status. In light of this finding, it is advisable to consider prophylactic antiviral nucleoside analog therapy before commencing chemotherapy treatment.
[lab data]
2023-10-04 HBsAg Nonreactive
2023-10-04 HBsAg (Value) 0.39 S/CO
2023-10-04 Anti-HBc Reactive
2023-10-04 Anti-HBc-Value 5.48 S/CO
2023-10-04 Anti-HCV Nonreactive
2023-10-04 Anti-HCV Value 0.05 S/CO
[exam findings]
= 27 None
[MedRec]
[consultation]
[chemotherapy]
Treatment Name: DVd (Daratumumab + Velcade® (bortezomib) + dexamethasone) - 2023-10-18 - https://www.chemoexperts.com/dvd-daratumumab-velcade-bortezomib-dexamethasone.html
Major toxicities of selected treatment regimens used for relapsed multiple myeloma - 2024-01-24 - https://www.uptodate.com/contents/image?imageKey=HEME%2F108257
[medication]
[evaluating osteoporotic changes after Xgeva discontinuation]
Bortezomib was administered on 2024-01-03, 2024-01-09, and 2024-01-16 (days 1, 7, and 14), deviating from the typical days 1, 4, 8, and 11 schedule in cycle 5 of the DVd regimen. The patient was admitted for Cycle 6 Day 1 treatment. Lab results on 2024-01-23 showed pancytopenia, a decreased eGFR of 53 mL/min/1.73m2, low serum albumin at 2.8 g/dL, and elevated total bilirubin at 0.73 mg/dL. However, these findings should not contraindicate treatment continuation.
The patient had previously been treated with several doses of Xgeva in the first half of 2023. Following this, multiple bone X-rays indicated osteoporotic or osteolytic changes. Therefore, reintroducing Xgeva to address the bone condition could be considered.
[macrocytic anemia]
The lab results indicate the presence of macrocytic anemia, which could be attributed to deficiencies in vitamin B12, folate, or copper. To alleviate the anemia, it may be advantageous to consider supplementation with vitamin B12 and/or folate.
Additionally, daratumumab and bortezomib in DVd regimen are associated with anemia.
[DVd Regimen: deviation from original schedule]
The patient was admitted for C4D1 of her daratumumab treatment, which is part of the DVd regimen in combination with bortezomib. The administration schedule for this regimen involves daratumumab on Days 1, 8, and 15 for Cycles 1, 2, and 3; then only on Day 1 for Cycles 4 through 8, followed by a monthly administration (every 28 days) thereafter.
This hospitalization marks the beginning of Cycle 4, and according to the regimen design, daratumumab should only be administered on Day 1 up to Cycle 8. Additionally, as per the regimen’s design, bortezomib is scheduled on Days 1, 4, 8, and 11 for Cycles 1 to 8, and in practice, it is administered concurrently with daratumumab.
Ref: https://www.darzalexhcp.com/pdfs/cp-142382v4-darzalex-maia-cassio-apollo-dosing-admin-guide.pdf
[to reassess bone health]
It is common practice to administer a single dose of a potent bisphosphonate (ie, zoledronic acid at 4 or 5 mg for a single dose) after stopping denosumab therapy to prevent rebound bone loss and fractures. Markers of bone resorption rebound and increase rapidly after denosumab discontinuation, and this can lead to increased loss of bone mineral density and the development of vertebral fractures, particularly in patients with baseline osteoporosis, with a history of prior fracture, or on continued aromatase inhibitor therapy.
The last 3 doses of Xgeva (denosumab 120mg) were administered on 2023-03-24, 2023-05-02, and 2023-06-06. Since it has been over 6 months since the last dose, and there are no hospital records of bisphosphonate use since then, it is recommended to reassess the patient’s bone health.
[reconciliation]
Currently, access to the PharmaCloud database is unavailable.
There has been a downward trend in eGFR readings over the past 2-3 weeks. Despite this, the patient’s current renal function does not necessitate any dose adjustments at this time.
No discrepancies have been identified in the active medication list.
The DVd regimen, which began on 2023-10-04, might have led to a decrease in IgA levels, yet they remain elevated along with FKLC and B2-Microglobulin.
2023-11-27 FKLC 139.0 mg/L
2023-11-27 FLLC 5.9 mg/L
2023-11-27 FK/FL ratio 23.56 ratio
2023-11-23 B2-Microglobulin 5746 ng/mL
2023-11-22 IgA 3460 mg/dL
2023-09-26 IgA 4568 mg/dL
2023-09-12 IgA 5331 mg/dL
Based on the lab results from 2023-11-28, the patient’s liver and kidney functions are grossly normal, indicating no need for dosage adjustments due to liver or renal concerns for now.
[pancytopenia after 2023-10-25 C2D1 DVd]
On 2023-10-25, DVd (C2D1) was administered, which resulted in the onset of pancytopenia. Appropriate measures, including the administration of G-CSF and blood transfusion, were promptly undertaken.
2023-11-01 WBC 2.70 x10^3/uL
2023-10-31 WBC 2.55 x10^3/uL
2023-10-25 WBC 2.57 x10^3/uL
2023-11-01 HGB 7.6 g/dL
2023-10-31 HGB 8.6 g/dL
2023-10-25 HGB 8.6 g/dL
2023-11-01 PLT 128 *10^3/uL
2023-10-31 PLT 42 *10^3/uL
2023-10-25 PLT 170 *10^3/uL
[withhold Diovan temporarily]
The latest blood pressure measurement, taken on 2023-11-01 at 12:59, was 100/52. Given the absence of current hypertension, it is advisable to temporarily withhold Diovan (valsartan) to reduce the potential for hypotension.
[DVd regimen]
This patient received lenalidomide from 2021 to 2023Q1 (and thalidomide prior to that). The DVd regimen is preferred for patients who are refractory to full doses of lenalidomide or to a lenalidomide-containing triplet regimen.
The patient started the DVd regimen in early Oct 2023, with the first dose (C1D1) administered on 2023-10-04, the second dose (C1D8) administered on 2023-10-11, and the third dose (C1D15) administered on 2023-11-17. This hospitalization is for the end of cycle 1.
These three daratumumab infusions were administered over 8 hours, 6 hours, and 4 hours, respectively, which effectively reduced the risk of infusion reactions.
The major toxicities of the DVd regimen include peripheral neuropathy, transient cytopenias, acute or delayed hypersensitivity reaction, fatigue, and nausea. Please continue to monitor the patient for these toxicities.
This patient received repeat prescriptions from our cardiology department for Licodin (ticlopidine), Urosin (atenolol), Zulitor (pitavastatin), Diovan (valsartan), and Ulstop (famotidine) on 2023-08-18, and from our neurology department for Syntam (piracetam) on 2023-07-26. There are no discrepancies, and all these medications are currently being used as prescribed.
[rising IgA levels in 2023]
Since the beginning of this year (2023), IgA levels have risen from the triple digits to the mid-four digits by August, suggesting that the disease may still be progressing.
Neutropenia has be mitigated with filgrastim (G-CSF)
Over the past three months, the IgA levels have been around 500 +- 50 mg/dL, relatively stable, but showing a slowly upward trend.
Revlimid (lenalidomide) has demonstrated a significantly increased risk of deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as risk of myocardial infarction and stroke in patients with multiple myeloma who were treated with lenalidomide and dexamethasone therapy. Please monitor for and advise patients about the signs and symptoms of thromboembolism as always.
Ninlaro (ixazomib) has been prescribed as a self-paid item and is not listed on PharmaCloud nor in the active prescriptions. Please make sure that the patient’s ANC be greater than 1000/mm3, platelets be greater than 75,000/mm3, and nonhematologic toxicities be at baseline or less than grade 1 (per prescriber discretion) prior to initiating a new cycle of therapy. It is recommended that patients who are seropositive for Varicella zoster virus (VZV) and herpes simplex virus (HSV) receive an antiviral prophylaxis with acyclovir or valacyclovir prior to receiving a proteasome inhibitor (bortezomib, carfilzomib, ixazomib), as there is an increased risk of reactivation if the proteasome inhibitor is used.
[lab data]
[exam findings]
[MedRec]
[surgical operation]
[consultation]
[chemotherapy]
2024-01-23 - panitumumab 6mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
2024-01-03 - panitumumab 6mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
2023-12-11 - (FOLFIRI plus panitumumab)
2023-11-21 - (FOLFIRI plus panitumumab)
2023-10-31 - (FOLFIRI plus panitumumab)
2023-10-09 - (FOLFIRI plus panitumumab)
2023-09-18 - (FOLFIRI plus panitumumab)
2023-08-29 - (FOLFIRI plus panitumumab)
2023-04-07 - (FOLFIRI plus panitumumab)
2023-03-17 - (FOLFIRI plus panitumumab)
2023-02-27 - (FOLFIRI plus panitumumab)
2023-02-08 - (FOLFIRI plus panitumumab)
2023-01-17 - (FOLFIRI plus panitumumab)
2023-01-03 - (FOLFIRI plus panitumumab)
2022-12-20 - (FOLFIRI plus panitumumab)
2022-12-06 - (FOLFIRI plus panitumumab)
2022-11-22 - (FOLFIRI plus panitumumab)
2022-11-08 - (FOLFIRI plus panitumumab)
2022-10-25 - (FOLFIRI plus panitumumab)
2022-10-11 - (FOLFIRI plus panitumumab)
2022-09-27 - (FOLFIRI plus panitumumab)
2022-09-13 - (FOLFIRI plus panitumumab)
2022-07-13 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr (FOLFIRI plus panitumumab)
2022-06-29 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr
2022-06-15 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr
2022-06-01 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr
2022-04-27 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr
2022-04-13 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr
2022-04-01 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
2022-03-23 - panitumumab 6mg/kg 90min
2022-03-18 - irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
2022-02-24 - irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
2022-02-11 - irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
2022-01-24 - irinotecan 120mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
[reconciliation]
The PharmaCloud database indicates that on 2024-01-22, the patient refilled prescriptions for Concor (bisoprolol), Zanidip (lercanidipine), Aprovel (irbesartan), and Xanax (alprazolam) at Cardinal Tien Hospital. These medications are currently being used, and no discrepancies in medication have been identified.
[sharp rise and subsequent decline of CEA and CA199]
Both tumor markers, CEA and CA199, showed a sharp increase starting in 2023Q3 and have recently shown a decrease (although not yet in the normal range). Given that the primary treatment, P-FOLFIRI, has been used for over a year and a half without adjustments, the reasons for the decline in tumor markers may warrant further investigation.
2023-10-25 CEA 55.55 ng/mL
2023-09-06 CEA 484.09 ng/mL
2023-08-29 CEA 581.20 ng/mL
2023-07-17 CEA 172.08 ng/mL
2023-06-17 CEA 30.15 ng/mL
2023-05-25 CEA 7.86 ng/mL
2023-03-30 CEA 2.33 ng/mL
2023-03-09 CEA 2.64 ng/mL
2023-01-31 CEA 2.44 ng/mL
2023-01-17 CEA 2.46 ng/mL
2023-01-03 CEA 2.54 ng/mL
2023-10-25 CA199 52.99 U/mL
2023-09-06 CA199 183.01 U/mL
2023-08-29 CA199 268.44 U/mL
2023-07-17 CA199 76.81 U/mL
2023-06-17 CA199 16.80 U/mL
2023-05-25 CA199 8.73 U/mL
2023-03-30 CA199 5.91 U/mL
2023-03-09 CA199 6.00 U/mL
2023-01-31 CA199 6.64 U/mL
2023-01-17 CA199 6.84 U/mL
2023-01-03 CA199 7.19 U/mL
The patient primarily receives medical care at Cardinal Tien Hospital. On 2023-08-28, refills were obtained for medications including metformin, pioglitazone, canagliflozin, bisoprolol, lercanidipine, irbesartan, rosuvastatin, and alprazolam. These drugs are mainly for the treatment of Type 2 Diabetes Mellitus and hypertension. As of now, these medications are accounted for in the active medication list and no discrepancies have been identified.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[addressing hemoptysis with inhaled tranexamic acid]
Today’s progress note indicated that the patient experienced a mild episode of coughing up blood last night. Should the hemoptysis persist, the use of inhaled tranexamic acid (500mg/5mL, up to five days) has been reported to effectively reduce the volume of hemoptysis, expedite its resolution, and potentially shorten the duration of hospitalization.
Ref: - Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018;154(6):1379. - Nebulized tranexamic acid for recurring hemoptysis in critically ill patients: case series. Int J Emerg Med. 2020;13(1):45.
I visited the patient around 11:15 on 2023-07-05 carrying the decitabine medication usage information. The patient was lying in bed and her awake husband was sitting in the bench by the window.
I first asked the patient’s husband how the patient’s recent condition was and whether the discomfort in the mouth had worsened or improved? The husband said that the patient is currently using the oral paste prescribed by the doctor, and the condition is manageable. He also asked if the infection was caused by the use of decitabine. I responded that since April, the patient’s white blood cell count has consistently remained around 2000 +- 500, and there was no significant fluctuation due to the administration of decitabine in mid-May. Although the effect of decitabine on white blood cells can’t be entirely ruled out, it does not seem to be the primary cause based on the observations.
[exam findings]
2024-01-23 lab data showed both DGH and Toxin A/B positive.
[TDM scheduling for optimized vancomycin treatment in CDI]
Lab data from 2024-01-23 confirmed positivity for both DGH and Toxin A/B.
For patients with severe or fulminant C. difficile infection, an initial oral dose of vancomycin can be 10 mg/kg, administered four times daily for 10 days, with a maximum dose of 500 mg per administration. In critically ill patients, the addition of intravenous metronidazole may be considered.
This patient exhibits impaired renal function as evidenced with an eGFR of 21 mL/min/1.73m², an elevated serum creatinine (2.94 mg/dL) and blood urea nitrogen (BUN) (31 mg/dL) on 2024-01-24. While the vancomycin manufacturer’s labeling lacks specific dosage adjustments for this degree of renal impairment, the low systemic absorption of vancomycin suggests dose modification may not be necessary.
Oral vancomycin 500mg QID has just been prescribed from 2024-01-23 for a duration of seven days, adhering to standard usage. Therapeutic drug monitoring (TDM) is recommended to be scheduled on day 3, specifically on 2024-01-26, with a blood sample to be drawn within 30 min before the next dose.
Ref: Does oral vancomycin use necessitate therapeutic drug monitoring? Infection. 2020 Apr;48(2):173-182. doi: 10.1007/s15010-019-01374-7.
[exam findings]
[MedRec]
[immunochemotherapy]
Apart from a mild case of hypokalemia (3.3mmol/L), the lab results from 2024-01-23 were largely normal. The decision to use oral potassium supplements can be based on clinical assessment and necessity.
The planned 6 cycles of TCHP therapy will be completed during this hospitalization. Subsequent treatment plans and follow-up schedules might be discussed with the patient to achieve a consensus through shared decision making. (The CT scan on 2023-12-01 revealed regression of the lesion in the right breast and the emergence of a new nodular lesion in the left breast.)
Lab results from 2023-11-01 showed normal values for CBC, WBC-DC, electrolytes, and liver and kidney function tests.
No moderate or severe treatment related adverse events have been documented. As a result, the 3rd cycle of the docetaxel, carboplatin, trastuzumab and pertuzumab chemotherapy regimen was administered on 2023-11-02 without any complications to date.
Review of PharmaCloud and HIS5 records revealed no medication reconciliation issues.
[exam findings] (not completed)
[MedRec]
[chemotherapy]
[recovery patterns of WBC and PLT after chemotherapy]
The last administration of pemetrexed plus carboplatin for this patient occurred on 2023-12-28.
The nadir for both WBC and PLT counts was observed on 2024-01-08, which aligns with the expected timeline for these side effects.
According to UpToDate, carboplatin tends to have a higher incidence of leukopenia and thrombocytopenia compared to pemetrexed.
Currently, both WBC and PLT levels are in the process of recovery.
2024-01-23 WBC 5.38 x10^3/uL
2024-01-19 WBC 4.21 x10^3/uL
2024-01-15 WBC 20.07 x10^3/uL
2024-01-11 WBC 1.54 x10^3/uL **
2024-01-08 WBC 1.01 x10^3/uL ***
2024-01-02 WBC 4.65 x10^3/uL
2023-12-27 WBC 5.20 x10^3/uL
2024-01-23 PLT 174 *10^3/uL
2024-01-19 PLT 97 10^3/uL
2024-01-15 PLT 42 *10^3/uL **
2024-01-11 PLT 137 *10^3/uL
2024-01-08 PLT 17 10^3/uL **
2024-01-02 PLT 108 *10^3/uL
2023-12-27 PLT 110 *10^3/uL
[lab data]
2023-12-28 Anti-HCV Nonreactive
2023-12-28 Anti-HCV Value 0.33 S/CO
2023-12-27 Anti-HBc IgM Nonreactive
2023-12-27 Anti-HBc IgM Value 0.09 S/CO
2023-12-27 HBsAg Nonreactive
2023-12-27 HBsAg (Value) 0.57 S/CO
2023-12-27 Anti-HBc Nonreactive
2023-12-27 Anti-HBc-Value 0.21 S/CO
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
anemia episode was observed on 2024-01-21
[lab data]
2022-10-24 Anti-HBc Reactive
2022-10-24 Anti-HBc-Value 6.32 S/CO
2022-10-24 HBsAg Nonreactive
2022-10-24 HBsAg (Value) 0.35 S/CO
2022-10-24 Anti-HCV Nonreactive
2022-10-24 Anti-HCV Value 0.13 S/CO
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[CEA marker trends and imaging updates]
The patient has been undergoing FOLFOX treatment since Dec 2022, for over a year, and has generally tolerated it well.
She is also receiving Baraclude (entecavir) for reactive Anti-HBc and Megejohn (megestrol acetate) for cachexia, with no discrepancies in medication identified.
The CEA marker showed a recent high in November 2023. There has been no updated imaging study since Oct 2023, which may warrant renewal.
[MedRec]
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[Vit B and CIPN: no clear recommendation, potential benefits remain]
B-Red (hydroxocobalamin) 1mg IM was administered on 2024-01-23 after chemotherapy to prevent oxaliplatin-induced neurotoxicity.
The year 2020 ASCO and joint ESMO/EONS/EANO guidelines concluded that clinicians should not offer vitamin B as a neuroprotectant agent to individuals receiving potentially neurotoxic chemotherapy.
Schloss et al. reported that vitamin B complex supplementation was statistically ineffective at preventing CIPN as compared to the placebo, although as indicated by the results of the Patient Neurotoxicity Questionnaire (PNQ), patients taking the vitamin B complex perceived a reduction in sensory peripheral neuropathy. Importantly, in cases of CIPN coexisting with vitamin B12 deficiency, patients did benefit from the oral supplementation of this medication. Lastly, Abe et al. reported that oral vitamin B12 supplementation did not help in the prevention of the CIPN onset. Their study did not include the control group and they compared the efficacy of B12 supplementation versus goshajinkigan—observed incidence of neuropathy was 88.9% and 39.3%, respectively.
Vitamin B complex supplementation cannot be recommended as the main way of CIPN prevention. Nevertheless, since such therapy does not impact the effectiveness of chemotherapy (with the exception of high doses of pyridoxine), and in some particular cases could potentially have an ameliorative effect, treatment with the vitamin B complex could be a safe and cheap solution.
Ref: Nutrients 2022, 14(3), 625; https://doi.org/10.3390/nu14030625
[exam findings]
[MedRec]
[chemotherapy]
Triple IST (hATG, CsA, EPAG) — Triple immunosuppressive therapy (IST) for severe AA (SAA) comprises eltrombopag (EPAG; a bone marrow stimulating agent) plus two immunosuppressive agents (horse antithymocyte globulin [hATG] and cyclosporine [CsA]). As discussed above, triple IST is generally preferred over treatment with hATG plus CsA alone (no eltrombopag). Ref: 2024-01-22 https://www.uptodate.com/contents/treatment-of-aplastic-anemia-in-adults
[managing leukopenia and thrombocytopenia in aplastic anemia]
A 58-year-old female, newly diagnosed with aplastic anemia, began treatment with antithymocyte globulin at a dosage of 3.5mg/kg daily for five days starting on 2024-01-16. Additionally, ciclosporin at 300mg daily, divided into two doses (approximately 6mg/kg), was initiated on 2024-01-22. To manage severe leukopenia, G-CSF (filgrastim) has been administered since 2024-01-20. Due to observed thrombocytopenia episodes with platelet counts below 20K/uL, the concurrent initiation of eltrombopag with standard immunosuppressive therapy (antithymocyte globulin and cyclosporine) can also be considered.
Given the patient’s relatively young age, it might be advisable to assess eligibility and seek a match for allogeneic hematopoietic cell transplantation in advance.
[MedRec]
[lab data]
2024-01-20 Anti-HCV Nonreactive
2024-01-20 Anti-HCV Value 0.16 S/CO
2024-01-20 HBsAg Nonreactive
2024-01-20 HBsAg (Value) 0.35 S/CO
2024-01-20 Anti-HBc Reactive
2024-01-20 Anti-HBc-Value 3.34 S/CO
[acute pancreatitis: supportive care on track, hepatic markers soar (ABD SONO reveals gallbladder sludge)]
This patient’s current primary medical concern is acute pancreatitis. Supportive therapy with fluid replacement and pain control (using normal saline and tramadol) is being effectively implemented.
Although vital signs, urine output, electrolytes, and serum glucose grossly remain within acceptable ranges, significant elevations were observed in hepatobiliary-related markers (AST, ALT, alkaline phosphatase, gamma-GT, and bilirubin) on 2024-01-20.
Abdominal sonography performed on 2024-01-22 revealed the presence of gallbladder sludge, which may represent a potential contributing factor requiring further management. Is this patient a candidate for cholecystectomy?
[MedRec]
[MedRec]
[surgical operation]
[lab data]
2023-05-30 Anti-HBc Reactive
2023-05-30 Anti-HBc-Value 3.37 S/CO
2023-05-30 Anti-HBs 80.54 mIU/mL
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[reconciliation]
Lab data from 2024-01-19 indicated generally normal levels across blood cell counts, electrolytes, and liver and kidney functions. Additionally, a review of the medication records revealed no discrepancies.
[Achrimobacter xylosoxidans bacteremia]
For treating Achromobacter xylosoxidans infections in patients without cystic fibrosis:
[radiotherapy]
[chemotherapy]
[exam findings] (not completed)
[MedRec]
[consultation]
[immunochemotherapy]
[transfusion in chemotherapy-induced anemia]
Given the patient’s renal impairment, a modified treatment regimen of nivolumab combined with gemcitabine and carboplatin was administered instead of the standard nivolumab, gemcitabine, and cisplatin therapy.
The patient’s hemoglobin levels have shown a consistent decline, indicating anemia:
Anemia is associated with gemcitabine (68%; grade 3: 7%; grade 4: 1%), carboplatin (21% to 90%), and nivolumab (26% to 41%; grades 3/4: <=3%). The downward trend in HGB might suggest insufficient red blood cell production to match the treatment schedule. A transfusion was performed on 2024-01-19, which is considered an appropriate action. If adverse reactions increase, modifying the administration interval or dose reduction could be further decided.
[diagnosis] - 2023-04-10 admission note
[past history] - 2023-01-12 admission note
[allergy]
[family history]
[lab data]
[exam findings]
[MedRec]
[consultation]
[multiteam]
[chemoimmunotherapy]
Medications prescribed by other departments are incorporated into the current medication list, and no discrepancies have been identified.
In addition to visiting our hemato-oncology department, the patient also consulted our urologist on 2023-07-07 and our cardiologist on 2023-07-14. The urologist prescribed Urief (silodosin) and the cardiologist prescribed Concor (bisoprolol). These medications were accurately added to the active formulary and no discrepancies were found during reconciliation.
According to the current PharmaCloud database, the patient refiled his prescription at Taipei City Hospital on 2023-06-21 for Algitab Chewable Tablets (alginic acid), Avamys Nasal Spray (fluticasone furoate), and Engene Eye Drops Patron (flavineadenine dinucleotide), all of which are valid for 28 days and are currently still valid. However, these medications are not yet on the patient’s active formulary at our hospital. This could lead to potential medication reconciliation discrepancies. It’s advisable for the primary care team to confirm whether these medications are still needed for the patient’s current clinical condition. If these medications are needed, they should be added to the patient’s active formulary accordingly.
Per the PharmaCloud database, this patient recently had an outpatient visit at Taipei City Hospital on 2023-05-24. He was prescribed Algitab, Broen-C, acetaminophen for oral use, and sulfamethoxazole eye drops for a 28-day duration. Most of these medications are intended to manage GI symptoms. Upon examination of the current medication list, equivalent therapeutic drugs have already been prescribed. Consequently, no issues were identified during the medication reconciliation process.
Based on the serum glucose level range of 288 mg/dL to 230 mg/dL, it appears that the patient’s underlying condition of type 2 DM is not well-controlled despite taking Galvus Met (vildagliptin + metformin) and Relinide (repaglinide). However, since there is no evidence of renal insufficiency (as of 2023-04-10 with Cre at 1.02mg/dL, eGFR at 75.67, and BUN at 21), the addition of Dibose (acarbose 100mg) 0.5# TIDAC is recommended if the high glucose level persists.
The recurrence of cancer has left the patient feeling helpless, and he has been visited by a psychiatrist, a counseling psychologist, and a social worker in early Feb 2023. He is currently still taking alprazolam, but his emotional state is stable.
The patient’s HbA1c has shown a slow decline trend, blood sugar readings were 145 to 164 mg/dL on 2/22 and 2/23, there is still room for improvement.
{Triple cancer - endometrium ca, rectal ca, RCC}
[exam findings]
[MedRec]
[myocardial injury indicators: rising hs-Troponin I]
Lab results indicate low CK levels, normal CK-MB, and a consistent increase in hs-Troponin I, suggesting myocardial injury.
The pattern of these biomarkers might point to several potential causes:
Given these findings, consulting a cardiologist may be beneficial for further evaluation and management.
[optimizing midodrine dosage for this hemodialysis patient]
Midodrine, dosed at 7.5mg, commenced pre-hemodialysis treatment QW135 from 2024-01-18, aiming to prevent post-dialysis hypotension, with current blood pressure around 90/50 mmHg. The dosage, confirmed via telephone with the nurse practitioner, aligns with the patient’s customary regimen.
(the following text is wrong and not posted)
Midodrine, at a dose of 7.5mg, has been initiated for post-hemodialysis treatment as of 2024-01-18, with current blood pressure readings around 90/50 mmHg.
Midodrine’s effectiveness is attributed to its major metabolite, desglymidodrine, generated through the deglycination process. The peak plasma concentration of midodrine occurs about 30 minutes post-administration, with a half-life of approximately 25 minutes. Desglymidodrine reaches peak levels in the blood between 1 to 2 hours after midodrine administration and has a half-life of 3 to 4 hours.
For patients undergoing thrice-weekly intermittent hemodialysis, initiating midodrine at a low dose, such as 2.5 mg once or twice daily, is advisable. Dosage can be adjusted based on individual response and tolerability, with careful monitoring.
[MedRec]
[SLE management]
Based on the PharmaCloud database, this patient had multiple admissions to TMUH before seeking treatment at our hospital around late 2023. Given that immunosuppressive agents were used prior to her current treatment, vigilant monitoring for signs of infection is recommended. Typically, immunizations should precede immunosuppressive therapy.
Exposure to UV light can trigger or worsen systemic lupus erythematosus (SLE) symptoms, though this varies among patients. About one-third may react to sun exposure, another third with prolonged exposure, and the rest may not react at all. Most SLE patients are advised to avoid direct or reflected sunlight and UV light sources, using sunscreens with a minimum SPF of 55 that block both UV-A and UV-B rays.
A recent study in the Annals of the Rheumatic Diseases has confirmed the renal protective effects of sodium glucose cotransporter 2 (SGLT2) inhibitors in lupus nephritis, both in mouse models and patients, suggesting significant clinical benefits of this treatment approach. (Reference: Onuora S., “SGLT2 inhibitors protect podocytes in lupus nephritis”, Nat Rev Rheumatol, 2023 Oct, 19(10): 605, DOI: 10.1038/s41584-023-01024-1, PMID: 37666997).
[lab data]
2024-01-18 Anti-HBc Nonreactive
2024-01-18 Anti-HBc-Value 0.42 S/CO
2024-01-18 HBsAg Nonreactive
2024-01-18 HBsAg (Value) 0.40 S/CO
2024-01-18 Anti-HCV Nonreactive
2024-01-18 Anti-HCV Value 0.15 S/CO
[MedRec]
[consultation]
[MedRec]
[surgical operation]
Pre-meal blood glucose levels were recorded at 132, 157, and 108 mg/dL on 2024-01-16, 2024-01-17, and 2024-01-18, respectively, indicating consistently elevated values. It is recommended that the patient continues with follow-up monitoring.
Upon review of the HIS5 records, no discrepancies in medication were identified.
[MedRec]
[immunochemotherapy]
[stage IV RCC on sunitinib: historical anemia, emergency event & HGB low]
This 53-year-old female patient with stage IV renal cell carcinoma (RCC) was started on sunitinib in late Nov 2023 after progression on cabozantinib. The patient had a history of anemia prior to starting sunitinib, with no hemoglobin (HGB) values within the normal range in 2023.
On 2024-01-16, the patient presented to the emergency department with suspected coffee-ground emesis. This was likely the primary cause of the recent anemia episode. However, sunitinib is known to be associated with an incidence of decreased HGB (26% to 79%; grades 3/4: 3% to 8%; grade 4: 2%) and hemorrhage (22% to 37%; grades 3/4: <=4%). Therefore, the historic low HGB value on 2024-01-16 cannot be definitively excluded as a side effect of sunitinib. The patient underwent a blood transfusion on the same day, which was a reasonable course of action. In addition, this patient also underwent multiple blood transfusions in 2023.
In the event of grade 3 or 4 hemorrhage, it is recommended to withhold sunitinib until resolution to <= grade 1 or baseline, then resume at a reduced dose or discontinue (depending on severity and persistence). Discontinue sunitinib if grade 3 or 4 hemorrhagic events do not resolve.
The standard dosage of sunitinib for advanced RCC is 50mg daily, but the patient is currently taking 12.5mg daily. This is a significant underdose, and there seems no room to further reduce the dose.
[exam findings]
[MedRec]
[chemotherapy]
[combining immunotherapy with chemotherapy in biliary tract tumors] - Ref: 2024-01-16 - https://www.uptodate.com/contents/systemic-therapy-for-advanced-cholangiocarcinoma
The current treatment regimen for advanced or metastatic biliary tract tumors for this patient is gemcitabine plus cisplatin.
Adding durvalumab to this regimen, as seen in the TOPAZ-1 trial, can enhances OS and response, without notably increasing toxicity. Similarly, pembrolizumab combined with gemcitabine and cisplatin, as demonstrated in the KEYNOTE-966 trial, also improves OS and is well-tolerated.
However, due to non-coverage by NHI and potential reimbursement issues, the addition of durvalumab or pembrolizumab may be more suitable for patients who can financially manage the costs.
[hyperuricemia, hyperkalemia, hypercalcemia]
Hyperuricemia, hyperkalemia, hypercalcemia were observed.
Hyperuricemia is treated with Fasturtec (rasburicase), Februic (febuxostat) and Rolikan (sodium bicarbonate).
Hyperkalemia is treated wtih Kalimate (calcium polystyrene sulfonate).
Hyperuricemia and hyperkalemia are frequent symptoms of tumor lysis syndrome. Another typical symptom is hyperphosphatemia, so it’s recommended to also monitor serum phosphate levels.
Hypercalcemia is treated with Miacalcic (calcitonin).
For severe hypercalcemia, the maintenance dose of calcitonin can be up to 8 units/kg (2023-11-29 70kg => 560 units) Q6H to Q12H, starting with an initial dose of 4 units/kg (280 units) Q12H. Since the current administration of 100 IU Q6H is below the recommended dosage, this might extend the duration of therapy. It’s advisable to limit calcitonin therapy to a period of 24 to 48 hours to avoid tachyphylaxis.
Given that the serum calcium level has exceeded 3.5 mmol/L (14 mg/dL) and if the reading does not obviously trend downwards, the combined use of calcitonin with bisphosphonates for a longer effect might be an option.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
Lab testing demonstrated a blood ferritin level of 18.9 ng/mL (2024-01-15), which falls below the normal range. Therefore, initiating oral iron supplementation may be beneficial to maintain adequate iron stores in this patient.
[reconciliation]
Leukopenia was identified in lab results on 2023-12-25. Consequently, the 5-FU bolus was omitted, and the Oxaliplatin dose was adjusted to 75mg/m2 from the originally planned 85mg/m2 for this chemotherapy session.
Despite vitamin B12 supplementation during this chemotherapy session, the patient’s mean corpuscular volume (MCV) on 2023-12-25 (79fL) remained below the lower limit of normal. This suggests mild microcytic anemia, potentially due to iron deficiency. Iron supplementation could therefore be helpful to raise the iron content of RBC, addressing this issue.
2023-12-04 HGB 11.5 g/dL < 13.5 and MCV 77.8 fL < 80. It is suggested to consider some vitamin and mineral supplements:
[lab data]
2023-12-20 CMV viral load assay 1040 IU/mL
2023-12-19 STR DNA fingerprint FINISH %
2023-12-18 CMV viral load assay 396 IU/mL
2023-12-12 CMV IgM Nonreactive
2023-12-12 CMV IgM Value 0.10 Index
2023-12-11 CMV viral load assay 74 IU/mL
2023-12-08 Anti-HBc Reactive
2023-12-08 Anti-HBc-Value 3.10 S/CO
2023-12-06 CMV viral load assay <35 IU/mL
2023-11-18 STR DNA fingerprint FINISH %
2023-11-13 EB VCA IgG Positive Ratio
2023-11-13 EB VCA IgG Value 3.6 Ratio
2023-11-10 HBsAg (NM) Negative
2023-11-10 HBsAg Value (NM) 0.539
2023-11-10 Anti-HBs (NM) Positive
2023-11-10 Anti-HBs value (NM) 59.1 mIU/mL
2023-11-10 Anti-HCV (NM) Negative
2023-11-10 Anti-HCV Value (NM) 0.047
2023-11-10 Anti-HBc (NM) Positive
2023-11-10 Anti-HBc Value (NM) 0.008
2023-11-09 VZV IgG Positive Index
2023-11-09 VZV-G Value 5.9 Index
2023-11-09 Mycoplasma IgM Negative Index
2023-11-09 Mycoplasma IgM Value 0.1 Index
2023-11-08 RPR Nonreactive
2023-11-08 EB VCA IgM Negative Index
2023-11-08 EB VCA IgM Value 0.1 Index
2023-11-08 CMV IgG Reactive
2023-11-08 CMV IgG Value 92.1 AU/mL
2023-11-08 CMV IgM Nonreactive
2023-11-08 CMV IgM Value 0.27 Index
2023-11-08 HIV Ab-EIA Nonreactive
2023-11-08 Anti-HIV Value 0.05 S/CO
2023-11-08 Anti HTLV I/II Nonreactive
2023-11-08 Anti HTLV I/II Value 0.08 S/CO
2023-10-20 IgE 14.5 IU/mL
2023-10-19 IgG 1831 mg/dL
2023-10-19 IgM 51.0 mg/dL
2023-10-19 IgA 421 mg/dL
2023-07-20 Ferritin (NM) 1548.71 ng/ml
2023-06-23 Ferritin (NM) 1258.84 ng/ml
2023-06-23 HLA DQ-high 02:01
2023-06-23 HLA DQ-high 04:02
2023-04-10 HLA A-high 24:02
2023-04-10 HLA A-high 33:03
2023-04-10 HLA B-high 40:01
2023-04-10 HLA B-high 58:01
2023-04-10 HLA C-high 03:02
2023-04-10 HLA C-high 07:02
2023-04-10 HLA DR-high 03:01
2023-04-10 HLA DR-high 08:09
[exam findings]
[MedRec]
2023-11-05 ~ 2023-12-08 POMR Hemato-Oncology Gao WeiYao
2023-08-19 ~ 2023-09-04 POMR Hemato-Oncology Gao WeiYao
2023-07-26 ~ 2023-08-01 POMR Hemato-Oncology Gao WeiYao
2022-10-04 SOAP Dermatology Zhou WeiTing
2022-09-01 SOAP Dermatology Zhou WeiTing
2022-06-20 SOAP Hemato-Oncology Zhang ShouYi
2022-06-18 SOAP Hemato-Oncology Zhang ShouYi
[chemotherapy]
[Ciclosporin dose optimization]
Following the adjustment of the daily dose to 220mg, observed serum trough levels have shown a gradual decline. To maintain the desired concentration range of 200-300 ng/mL, an increase in the daily dose to 240mg is recommended.
The administration of Grancicure (ganciclovir) 500mg Q12H IVD has effectively reduced the CMV viral load. Starting from 2024-01-17, Grancicure will be replaced with Valcyte (valganciclovir) 900mg QD PO.
Also note that the patient’s WBC count and HGB level are gradually decreasing.
2024-01-15 WBC 2.30 x10^3/uL
2024-01-12 WBC 2.24 x10^3/uL
2024-01-08 WBC 3.89 x10^3/uL
2024-01-06 WBC 3.59 x10^3/uL
2024-01-04 WBC 4.30 x10^3/uL
2024-01-02 WBC 4.96 x10^3/uL
2024-01-15 HGB 7.3 g/dL
2024-01-12 HGB 8.6 g/dL
2024-01-08 HGB 9.3 g/dL
2024-01-06 HGB 9.3 g/dL
2024-01-04 HGB 7.4 g/dL
2024-01-02 HGB 10.2 g/dL
[Sandimmun injection (Ciclosporin) TDM]
Following the recent ciclosporin trough level of 416.5 ng/mL on 2024-01-02, the Sandimmun injection dosage has been adjusted from 250mg to 220mg daily. To monitor the effectiveness of this adjustment, it is kindly requested a new blood sample four days after the adjustment, to be drawn prior to the scheduled administration, for another trough level test.
[steady rise, time to tune down: ciclosporin level management - Sandimmun injection (Ciclosporin) TDM]
This patient has been taking ciclosporin 275mg QD since 2023-12-12. Lab results for ciclosporin trough levels on 2023-12-15, 2023-12-18, 2023-12-21, and 2023-12-25 showed values of 152, 222, 292, and 318 ng/mL, respectively. Based on this monotonic trend, if the current dose is continued, the trough level could exceed the recommended upper limit of 400 ng/mL by the end of 2023 or early 2024. Therefore, it is recommended to reduce the dose to 250mg QD and recheck the trough concentration 4 days after the change.
The attending physician Dr. Gao held an interprofessional practice and patient family meeting in the ward conference room at 15:00 on 2023-09-25, to introduce the patient to the importance, possible risks, and prognosis of allogeneic peripheral blood stem cell transplantation in the treatment plan, and to answer questions from patients and their families. The patient did not ask the pharmacist any specific questions during the meeting. In a chat with the patient after the meeting, I emphasized the importance of controlling potential post-transplant infections.
[family history]
[exam findings]
[consultation]
[radiotherapy]
[immunochemotherapy]
2023-12-12 - paclitaxel 80mg/m2 120mg NS 400mL 3hr + topotecan 0.75mg/m2 1.2mg NS 40mL 30min D1-3 (He JingLiang)
2023-11-20 - bevacizumab 15mg/kg 900mg NS 100mL 90min + paclitaxel 80mg/m2 120mg NS 500mL 3hr + topotecan 0.75mg/m2 1.2mg NS 40mL 30min D1-3 (Xia HeXiong)
2023-09-28 - topotecan 0.75mg/m2 1.4mg NS 40mL 30min D1-3 (Xia HeXiong)
2023-02-03 - bevacizumab 15mg/kg 900mg NS 100mL 90min + paclitaxel 175mg/m2 295mg NS 500mL 3hr + carboplatin AUC 5 350mg NS 250mL 2hr (Xia HeXiong)
2022-12-01 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)
2022-11-10 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)
2022-10-21 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)
2022-09-01 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)
2022-08-12 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)
2021-06-10 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)
2021-05-28 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)
2021-05-21 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)
2021-05-13 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)
2021-05-07 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)
2021-04-28 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)
2021-04-20 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)
[levofloxacin dose adjust needed! eGFR 12 recommend 500mg QOD per Sanford Guide]
The Cravit (levofloxacin) dosage for this patient with an eGFR of 12.03 (2024-01-15) requires adjustment based on the Sanford Guide recommendations. While the current regimen uses 750mg QOD, the recommended regimen for this eGFR range is 750mg once followed by 500mg Q48H. Therefore, it is recommended to reduce the dose to 500mg QOD to align with the Sanford Guide for optimal safety and efficacy.
Imaging and Disease Status: MRI (2023-09-07) and CT (2023-12-07) both indicate disease progression, aligning with the rising CEA levels over the past year.
Renal Function: Deteriorated in late Oct to early Nov 2023, with partial improvement but still not meet normal levels. Latest eGFR value was below 30 mL/min/1.73m2.
Medication Recommendations:
[renal function follow-up]
On 2023-11-02, the patient’s serum creatinine reached a recent peak of 5.29 mg/dL and has since stabilized around the 2.2 - 2.5 mg/dL range. The patient, 61F, 62.9 kg, has a calcuated CrCl of 23 mL/min.
The current prescription of Tapimycin (piperacillin and tazobactam) at a dosage of 2.25g IVD Q6H is appropriate.
[rapid weight loss]
The patient experienced a rapid weight loss of over 20 kg within two weeks, dropping from 83.2 kg on 2023-11-01 to 62.9 kg by 2023-11-15.
Currently, the patient is being treated with furosemide and bumetanide, both of which are potent diuretics. Excessive use of these medications can result in significant diuresis, leading to water and electrolyte depletion. Consequently, close medical monitoring is essential, and the dosage and administration schedule should be tailored to the specific needs of the patient.
[renal function]
2023-10-30 BUN 43 mg/dL, eGFR 13.62 mL/min/1.73m2, Cre 3.61 mg/dL -> CrCl 21 mL/min (Cockcroft-Gault).
For patients with a CrCl of 20 to 39 mL/minute, the recommended dose of topotecan is reduced to 0.75 mg/m2 - this was the dose administered on 2023-09-28.
While the manufacturer’s labeling does not provide dosage adjustments for CrCl <20 mL/minute, it can be inferred that the dosage restrictions for this range would be even more stringent. Given the patient’s consistent decline in renal function over time, it is crucial to exercise caution when using this medication and to closely monitor for any adverse reactions.
[rapid weight gain]
According to the HIS5 records, the patient’s body weight was 67.5kg on 2023-09-20 and increased to 83kg by 2023-10-30. This significant weight gain could suggest the presence of edema or potential heart failure. Further evaluation is recommended.
[exam findings]
[MedRec]
[chemotherapy]
Liposomal Irinotecan drug information - 2024-01-15 - https://www.uptodate.com/contents/liposomal-irinotecan-drug-information
Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) for advanced pancreatic and biliary cancer - 2023-12-25 - https://www.uptodate.com/contents/image?imageKey=ONC%2F89668
Cycle length: 4 weeks.
Regimen
Pretreatment considerations:
Monitoring parameters:
Suggested dose modifications for toxicity:
Treatment protocols for pancreatic cancer - 2023-12-25 - https://www.uptodate.com/contents/treatment-protocols-for-pancreatic-cancer
[reconciliation]
This patient was admitted for her second dose of the liposomal irinotecan + leucovorin + fluorouracil regimen on 2024-01-14. She tolerated the treatment.
Her hypokalemia, which was low at 2.5 mmol/L on 2024-01-12, improved to 3.6 mmol/L by 2024-01-15. No medication discrepancies were identified.
[revise nab-paclitaxel sequence to ensure treatment efficacy]
Concerns have arisen regarding a deviation from the established administration sequence for the gemcitabine plus nab-paclitaxel regimen. The protocol explicitly mandates administering nab-paclitaxel first, followed by gemcitabine. However, recent administrations reversed this sequence, potentially compromising treatment efficacy. To ensure optimal outcomes, it is recommended to revert to the original protocol’s sequence.
Ref: Increased survival in pancreatic cancer with nab-paclitaxel plus gemcitabine. N Engl J Med. 2013 Oct 31;369(18):1691-703. doi: 10.1056/NEJMoa1304369. Epub 2013 Oct 16. PMID: 24131140; PMCID: PMC4631139.
[disease progress: comfort first, intensive chemo might not fly]
A recent CT scan on 2023-11-29 unfortunately indicated disease progression.
There is an article reporting a comparative effectiveness cohort study, FOLFIRINOX was associated with improved survival of approximately 2 months compared with gemcitabine plus nab-paclitaxel and was also associated with fewer posttreatment complications. A randomized clinical trial comparing these first-line treatments is warranted to test the survival and posttreatment hospitalization (or complications) benefit of FOLFIRINOX compared with gemcitabine plus nab-paclitaxel. Ref: Comparison of FOLFIRINOX vs Gemcitabine Plus Nab-Paclitaxel as First-Line Chemotherapy for Metastatic Pancreatic Ductal Adenocarcinoma. JAMA Netw Open. 2022 Jun 1;5(6):e2216199. doi: 10.1001/jamanetworkopen.2022.16199. PMID: 35675073; PMCID: PMC9178436.
Given the patient’s currently compromised performance status (ECOG PS 4 as of 2023-12-25 progress note), intensive chemotherapy might not be the most suitable option. Therefore, best supportive care or a less intensive regimen like mFOLFOX6 might be more appropriate at this time.
According to PharmaCloud, this patient has only received medical treatment at TSGH in the last three months. However, the last date of treatment was on 2023-06-21, and there are currently no active prescriptions from TSGH. Therefore, no medication reconciliation issues have been found.
[exam findings]
[chemotherapy] (not completed)
[exam findings]
[MedRec]
[chemotherapy]
Lab results on 2024-01-12 were grossly normal with no evidence of a contraindication to docetaxel administration.
[lab data]
2023-06-13 Anti-HBs 0.00 mIU/mL
2023-06-13 HBsAg Reactive
2023-06-13 HBsAg (Value) 6203.60 S/CO
2023-06-13 Anti-HCV Nonreactive
2023-06-13 Anti-HCV Value 0.17 S/CO
2023-05-23 HBeAg Nonreactive
2023-05-23 HBeAg (Value) 0.949 S/CO
2023-05-23 HBsAg Reactive
2023-05-23 HBsAg (Value) 5353.06 S/CO
2023-05-02 P.jiroveci DNA-Sp Undetectable
2023-05-02 CMV viral load assay <35 IU/mL
2023-05-02 EBV DNA PCR Not deteceted copies/mL
2023-04-29 Gamma 25.9 %
2023-04-28 B2-Microglobulin 6183 ng/mL
2023-04-27 HIV Ab-EIA Nonreactive
2023-04-27 Anti-HIV Value 0.04 S/CO
2023-04-27 LDH 344 U/L
[exam findings]
[immunochemmotherapy]
2024-01-23 - trastuzumab 600mg SC 3min + docetaxel 75mg/m2 110mg NS 250mL 2hr (Gao WeiYao)
2023-12-26 - trastuzumab 600mg SC 3min + docetaxel 75mg/m2 116mg NS 250mL 2hr (Gao WeiYao)
2023-12-19 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)
2023-11-28 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)
2023-10-31 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)
2023-10-12 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)
2023-09-21 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)
2023-09-07 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)
2023-07-04 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)
2023-06-13 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 1hr (Wang ShengLin)
2023-03-29 - epirubicin 90mg/m2 157mg NS 100mL 30min + cyclophosphamide 600mg/m2 1044mg NS 500mL 1hr (EC(90) Q3W)
2023-02-17 - epirubicin 90mg/m2 155mg NS 100mL 30min + cyclophosphamide 600mg/m2 1033mg NS 500mL 1hr (EC(90) Q3W)
2023-05-23 ~ Femara (letrozole)
2023-05-19 ~ 2023-05-24 - Cytotec (misoprostol)
Pertuzumab - Adult Dosing - 2024-01-03 - https://www.uptodate.com/contents/pertuzumab-drug-information
2023-12-26 CA-153 (NM) 118.131 U/ml
2023-12-12 CA-153 (NM) 110.748 U/ml
2023-06-20 CA-153 (NM) 44.155 U/ml
2023-04-03 CA-153 (NM) 64.922 U/ml
2023-02-06 CA-153 50.7 U/mL
2023-12-26 CEA (NM) 12.156 ng/ml
2023-12-12 CEA (NM) 17.145 ng/ml
2023-06-20 CEA (NM) 27.607 ng/ml
2023-04-03 CEA (NM) 35.020 ng/ml
2023-02-06 CEA 24.89 ng/mL
[prophylactic G-CSF for post-chemotherapy leukopenia]
This patient is scheduled to receive her second session of trastuzumab + docetaxel on 2024-01-23. Following her first session on 2023-12-26, she experienced a nadir WBC count of 0.48K/uL on 2024-01-02, one week later. G-CSF (filgrastim) 300mg daily from 2024-01-03 to 2024-01-05 successfully mitigated the leukopenia. However, due to a recent downward trend in WBC counts across the past three data points, prophylactic G-CSF is recommended for potential standby use.
[Neutropenia and Febrile Episode]
The patient recently experienced an episode of grade 4 neutropenia (severely low white blood cell count) on 2024-01-02. This is likely due to the combined effects of the chemotherapy medications trastuzumab and docetaxel, with docetaxel likely playing a stronger role.
2024-01-02 WBC 0.48 x10^3/uL
2023-12-26 WBC 6.86 x10^3/uL
2024-01-02 Neutrophil 0.0 %
2023-12-26 Neutrophil 82.2 %
To address the neutropenia, the patient received:
Additionally, the patient experienced a fever with a peak temperature of 39°C in the night of 2023-01-02. This fever has been successfully controlled with the administration of Cefim (cefepime 2g Q8H).
No identification of medication reconciliation issues.
In continuation of the previous pharmacist note.
{head and neck… not completed}
[exam findings]
[chemotherapy]
[episodic hyperuricemia: inconsistent Feburic use impedes control]
The patient exhibited episodic hyperuricemia throughout the past year, suggesting inadequate control of his uric acid levels.
In response to these hyperuricemic episodes, Feburic therapy was administered during several hospitalizations. However, outpatient visits did not consistently prescribe this medication, potentially contributing to the elevated serum uric acid levels.
Therefore, it is recommended to consider either extending Feburic therapy or exploring alternative options such as benzbromarone (on prescription at the OPD visits) for improved management of serum urate levels.
[exam findings]
[medication]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[hyperuricemia]
During this hospitalization, the patient experienced a significant increase in serum uric acid levels. Feburic (febuxostat) 80mg QD was initiated to address this.
If the elevated uric acid levels persist despite Feburic therapy, the addition of benzbromarone may be considered for further urate reduction.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[reconciliation]
The patient received repeat prescriptions for Rivotril (clonazepam) and Mirtapine (mirtazapine) at NTUH on 2023-11-13, followed by refills on 2023-12-07 and 2024-01-01. However, these medications are currently not listed as active in her medication record. Here are some possible explanations:
Therefore, it is recommended to understand the reason for the non-use of the prescribed medications will help determine the most appropriate course of action.
Currently, PharmaCloud access is unavailable.
Following the initiation of a dose-reduced FOLFIRI regimen, with the 3rd session starting on 2023-12-01, the patient has not experienced vomiting or nausea and reports good sleep and appetite.
No discrepancies in medication have been identified in the HIS5 records.
[MedRec]
[chemotherapy]
Comparison of tyrosine kinase inhibitors used for chronic myeloid leukemia - 2024-01-10 - https://www.uptodate.com/contents/image?imageKey=HEME%2F89930
| Agent | Dosing frequency and timing in relation to food | Dose adjustments for baseline kidney/liver dysfunction | Major toxicities | Other |
|---|---|---|---|---|
| Imatinib | Daily (or twice daily) with food | Yes (kidney, liver) | Bone marrow suppression; fluid retention/edema; gastrointestinal effects; heart failure; hepatotoxicity. | Longest record of safety data |
| Nilotinib | Twice daily without food | Yes (liver) | Bone marrow suppression; cardiovascular events; electrolyte imbalance; hepatotoxicity. Black box warning: QT prolongation (screening required). | _ |
| Dasatinib | Daily with or without food | No | Bone marrow suppression; pleural/pericardial effusions; pulmonary arterial hypertension; QT prolongation; aspirin-like effect. | _ |
| Bosutinib | Daily with food | Yes (kidney, liver) | Bone marrow suppression; fluid retention/edema; gastrointestinal effects. | _ |
| Ponatinib | Daily with or without food | Yes (liver) | Bone marrow suppression; fluid retention/edema; gastrointestinal effects; heart failure; hypertension; pancreatitis; aspirin-like effect; arterial thrombosis. Black box warning: cardiovascular events; hepatic toxicity. | Active against BCR::ABL1 T315I mutation; limited long-term safety data |
| Asciminib | Daily or twice daily without food | No | Upper respiratory tract infections; musculoskeletal pain; fatigue; nausea; rash; and diarrhea. Hypertriglyceridemia; cytopenias; elevated creatine kinase; hepatotoxicity; pancreatitis. | Active against BCR::ABL1 T315I mutation; limited long-term safety data |
[nilotinib]
This patient is newly diagnosed with CML.
Lab data: 2024/01/05 - BCR/abl Philadelphia chromosome (qualitative) - Presence of mutation.
Absence of blasts in recent WBC DC makes the diagnosis of advanced CML (accelerated phase or blast phase) highly improbable. Chronic phase CML is therefore the most likely diagnosis.
BCR-ABL1 tyrosine kinase inhibitors (TKIs) are the first-line therapy for all CML phases, except for specific contraindications like pregnancy.
Initial CML treatment typically employs either imatinib or a second-generation TKI (dasatinib, nilotinib, bosutinib). Other TKIs (ponatinib, asciminib) are reserved for refractory patients or those with specific mutations (e.g., T315I). Notably, nilotinib is currently the patient’s TKI of choice.
Nilotinib is known to prolong the QT interval. Monitoring for and correcting hypokalemia, hypomagnesemia, and pre-existing QTc prolongation are crucial before and during nilotinib treatment. Regular ECGs (baseline, 7 days after initiation, periodic) are essential to track QTc, especially after dose adjustments.
Sudden deaths have been reported with nilotinib. Contraindications include hypokalemia, hypomagnesemia, and long QT syndrome. Concomitant medications that prolong the QT interval or strongly inhibit CYP3A4 should be avoided. Nilotinib intake should be separated from food by at least 2 hours (before) and 1 hour (after).
[reconciliation]
This patient’s primary hospital is New Taipei City Hospital according to PharmaCloud database. On 2024-01-09, refills were prescribed for several medications: Gaslan, Periscon (mosapride), Vesicare (solifenacin), Harnalidge (tamsulosin), Eurodin (estazolam), Meptin-Mini (procaterol hydrochloride hemilydrate), Colin Soln (chlorpheniramine maleate), and Allevo (levocetirizine dihydrochloride).
However, these refilled medications are not currently listed as active in the patient’s record. Please verify with the patient whether he still require these medications and, if clinically necessary, ask him or his family member to bring them to the hospital.
Note that Tasigna (nilotinib 150mg) 2# Q12H prescribed on 2024-01-05 in the outpatient clinic is currently being used without any identified issues.
[MedRec]
[radiotherapy]
[chemotherapy]
The lab results on 2024-01-07 were grossly normal and ECOG PS 1, no obvious contraindication to the administration of FOLFOX.
[exam findings]
[consultation]
[radiotherapy]
[chemotherapy]
Vinorelbine - 2024-01-10 - https://www.uptodate.com/contents/vinorelbine-drug-information
dosage not correct?
[lab data]
2023-05-23 Anti-HBc Reactive
2023-05-23 Anti-HBc-Value 9.12 S/CO
2023-05-23 Anti-HCV Nonreactive
2023-05-23 Anti-HCV Value 0.16 S/CO
2023-05-23 HBsAg Reactive
2023-05-23 HBsAg (Value) 3336.74 S/CO
2023-05-23 Anti-HBs 0.53 mIU/mL
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[labs confirm HBV: Vemlidy maintained, medication compliance assured]
Lab results (2023-05-23) showed HBsAg and anti-HBc reactive and Vemlidy (tenofovir alafenamide) is currently in use, no medication discrepany found.
After 5 days of hydroxyurea treatment (500mg BID from 2024-01-04 to 2024-01-08), the blast percentage in peripheral blood significantly reduced from nearly 20% to below 10%.
Hydroxyurea can be used off-label for cytoreduction in AML, effectively normalized the WBC count to 4.1K/uL by 2024-01-08. Consequently, further administration of hydroxyurea is currently unnecessary.
[exam findings]
[MedRec]
[immunochemotherapy]
[anemia]
Compared to the previous session on 2023-12-25, the dosage of Irinotecan and fluorouracil administered during this session on 2024-01-08 was increased.
The patient’s HGB level remains low at 7.8g/dL as of 2024-01-08. Available lab data indicates persistent anemia since at least June 2023, with no recovery to normal levels. If the anemia becomes symptomatic, RBC transfusion may be necessary.
The patient has already received several blood transfusions throughout the previous months, specifically on 2023-08-30, 2023-11-13, and 2023-12-11.
[anemia]
Hemoglobin has been around 7 to 8 g/dL for the past two months. The FOLFIRI dose has been reduced during this hospitalization. If anemia is symptomatic, please perform RBC product transfusion as clinically indicated.
[anemia]
In the pharmacist note dated 2023-11-16, the following assessment was made: Considering the already reduced dose of the FOLFIRI regimen, further alleviation of anemia severity might necessitate lengthening the treatment intervals, potentially impacting the expected therapeutic effectiveness. In the recent two administrations (irinotecan on 2023-11-27 and 2023-12-11: 235mg; 5-FU on 2023-11-27 and 2023-12-11: 3670mg), both irinotecan and 5-FU doses were increased compared to the previous administration (irinotecan on 2023-11-14: 190mg; 5-FU on 2023-12-11: 2690mg), while maintaining a biweekly interval. Recent data may indicate that the rate of hemoglobin supplementation is not keeping pace with the anemia caused by the treatment. Consequently, in subsequent therapy sessions, blood transfusions may become a necessary adjunct to the treatment regimen.
[anemia]
Laboratory data indicated episodes of anemia. Blood transfusions were appropriately administered to the patient on 2023-08-30 and 2023-11-13.
The patient is currently being treated with Avastin and a reduced dose of the FOLFIRI regimen. Bevacizumab is less commonly associated with anemia. Given that the dose of the FOLFIRI regimen has already been reduced, further mitigation of the severity of anemia might require extending the treatment intervals, which could potentially affect the anticipated therapeutic efficacy.
Lab results:
2024-01-08 NT-proBNP > 35000.0 pg/mL
2024-01-08 CKMB 5.5 ng/mL
2024-01-08 hs-Troponin I 62.9 pg/mL
2024-01-08 CK 86 U/L
2024-01-08 ECG
2024-01-08 CXR
Potential causes:
It might be beneficial to consult a cardiologist.
[lab data]
2023-12-04 FKLC 135.0 mg/L
2023-12-04 FLLC 178.0 mg/L
2023-11-28 Protein, total 5.9 g/dL
2023-11-28 Albumin 35.2 %
2023-11-28 Alpha-1 2.3 %
2023-11-28 Alpha-2 14.6 %
2023-11-28 Beta 21.9 %
2023-11-28 Gamma 26.0 %
2023-11-28 M-peak Positive
2023-11-28 A/G Ratio 0.50
[MedRec]
[exam findings]
[MedRec]
[chemotherapy]
[reconciliation]
A repeat prescription for Anoro Ellipta for the patient’s COPD, issued on 2023-11-15 by our pulmonologist, has been added to the active medication list.
[reduced CEA growth after pemetrexed-cisplatin initiation]
The patient’s CEA level doubled within a month, from 2023-11-14 to 2023-12-15. Notably, this rapid increase seems to have slowed down in the following 21 days (2023-12-15 to 2024-01-05), with only a 12% increase observed. The initiation of pemetrexed + cisplatin therapy on 2023-12-12 may be contributing to this slowdown.
[MedRec]
[reconciliation]
The medications prescribed by both your cardiologist and psychosomatic medicine specialist on 2023-10-19 are currently in use without any discrepancies. These repeat prescriptions will expire soon. Please remind the patient to consider scheduling follow-up appointments with both specialists before the prescriptions expire, if clinically necessary.
[MedRec]
[exam findings]
[surgical operation]
[radiotherapy]
[chemotherapy]
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[History]
[exam findings]
[chemotherapy]
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[tumors have decreased in size]
On 2023-10-30, a gynecologic ultrasound revealed a large pelvic mass measuring 202 mm x 79 mm. A debulking surgery performed on 2023-11-06 confirmed the tumor to be high-grade serous adenocarcinoma. Following this, a regimen of paclitaxel and carboplatin was initiated on 2023-11-22, with the third cycle administered during this hospitalization on 2024-01-05. Subsequent gynecologic ultrasounds on 2023-12-06 and 2023-12-20 showed a reduction in the size of the pelvic mass to 97 x 40 mm and 63 x 31 mm, and then to 67 x 33 mm and 37 x 25 mm, respectively, indicating a decrease in size.
The patient, with an ECOG Performance Status of 0, had lab results that were generally normal as of 2024-01-01. Currently, access to the patient’s PharmaCloud records is unavailable. However, a review of HIS5 records revealed no discrepancies in medication.
[lab data]
2023-12-05 EBV DNA quantative PCR <35 IU/mL
2023-12-04 HCV RNA-PCR quantative Target Not Detected IU/mL
2023-11-28 HBsAg Nonreactive
2023-11-28 HBsAg (Value) 0.35 S/CO
2023-11-28 Anti-HCV Reactive
2023-11-28 Anti-HCV Value 14.16 S/CO
2023-11-28 Anti-HBc Nonreactive
2023-11-28 Anti-HBc-Value 0.21 S/CO
2023-11-28 Anti-HBs 1.51 mIU/mL
[exam findings]
[MedRec]
[radiotherapy]
[chemotherapy]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
The patient is properly hydrated and Cefim (cefepime) has been dose adjusted for the patient’s renal function. G-CSF (filgrastim) is used for neutropenia. No medication discrepancies are found.
The entirety of the oral medications listed on the active medication list are compatible with enteral feeding administration.
All of the oral drugs on the list of active medications can be fed by tube.
[exam findings]
2024-01-01, 2023-12-11 KUB
2023-12-12 MRI - brain
2023-10-20 Patho - bone exostosis
2023-10-18 Nerve Conduction Velocity, NCV
2023-10-17 PET
2023-10-16 CT - chest
2023-10-14 MRI - L-spine
2023-10-13 L-spine AP + Lat. (including sacrum)
2023-10-12 MRI - brain
2023-10-12 CT - brain
2023-10-06 Nasopharyngoscopy
2023-10-06 SONO - ENT head and neck soft tissue
YYYY-MM-DD many omitted …
2022-09-30 KUB
2022-09-19 CXR
2022-09-16 Whole body PET scan
2022-09-09 CT - abdomen
2022-09-08 Patho - stomach biopsy
2022-09-08 Esophagogastroduodenoscopy, EGD
2022-09-08 SONO - abdomen
2022-09-02 ECG
2021-10-12, 2020-11-02 SONO - neurology
2019-12-02 Carotid phonoangiograph, CPA
[MedRec]
[consultation]
[immunochemotherapy]
R-ESHAP (rituximab, etoposide, methylprednisolone, cytarabine, cisplatin) - from 2023-11-17 https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-patients-who-are-medically-fit
The latest lab results, drawn on 2024-01-03, show that the patient’s neutropenia has resolved.
The sputum aerobic culture, drawn on 2023-12-22, grew S. aureus (MRSA). The patient was started on Targocid (teicoplanin) on 2023-12-12 and continued on this medication until 2024-01-02. Avelox (moxifloxacin) was started on 2023-12-27 and is still being used.
Both CRP and PCT levels on 2024-01-04 were undetectable. Given this, kindly reassess whether the patient still exhibits any potential signs of infection.
Leukopenia was observed in early Nov, approximately 1 to 2 weeks after the patient first started the R-ESHAP regimen on 2023-10-24. The WBC reading has since returned to almost normal, and no further treatment is currently required.
Tube feeding is possible with all oral medications included in the active prescription.
The CNS depressant estazolam might enhance the CNS depressant effect of tramadol, so please monitor any adverse effects as always.
[exam findings]
[MedRec]
[chemotherapy]
Ibrance (palbociclib 125mg -> 100mg since 2024) 1# QDCC - 2022-09-07 ~ 2024-01-24 ongoing (21 days of 28 days) Kisqali (ribociclib 200mg) 3# QD - 2020-10-07 ~ 2022-08-03 (21 days of 28 days)
Femara (letrozole 2.5mg) 1# QD - 2017-02-20 ~ 2018-10-01 (repeat prescription)
[neutropenia]
The patient’s WBC count has been gradually declining for a long time. In late 2023, the count dropped to less than 2K/uL, which is considered grade 3 neutropenia.
The patient is currently taking fulvestrant and palbociclib as the main treatment medications. Fulvestrant was started on 2020-10-07, and palbociclib was started on 2020-09-07, to replace ribociclib.
The incidence of neutropenia for fulvestrant is 2%, with 1% grade 3 and <1% grade 4. The incidence of neutropenia for palbociclib is 80-83%, with 55-56% grade 3 and 10-11% grade 4. Therefore, neutropenia is more likely to be attributed to palbociclib.
It is recommended considering a palbociclib dose reduction in future cycles if recovery from grade 3 neutropenia is prolonged (>1 week) or if grade 3 neutropenia recurs on day 1 of subsequent cycles.
There is no evidence of prolonged neutropenia yet, but the dose of palbociclib has been reduced from 125mg daily to 100mg daily since 2024. This is a conservative approach.
{not completed}
[past history]
[family history]
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[neutropenia]
(not used) The patient’s last chemotherapy treatment before the lab result on 2023-12-28 was on 2023-08-08. Due to the long time interval between the treatment and the neutropenia episode, it is difficult to conclude with certainty that the neutropenia was directly caused by the previous chemotherapy.
A 28-day supply of oral etoposide was prescribed on 2023-11-16. This medication carries a known risk of leukopenia, with an incidence ranging from 60% to 91%. The severity can reach grade 4 in 3% to 17% of cases, with the nadir typically occurring 7 to 14 days after administration and recovery expected by day 20.
In response to the patient’s leukopenia, two days of Granocyte (lenograstim 250ug) were promptly administered.
The patient recently renewed his repeat prescription for Diovan (valsartan) for a 28-day supply on 2023-08-07. This medication has been added to the active list of medications without an identified reconciliation problem.
According to the PharmaCloud database, this patient regularly refills his prescription for Diovan (valsartan) to treat his primary hypertension. This medication was correctly added to the active formulary and no issues were identified during the medication reconciliation process.
According to PharmaCloud data, this patient has only sought medical treatment at our hospital. No issues with medication reconciliation were identified.
The latest lab data, collected on 2023-06-06, shows largely normal results and readings from the TPR panel are stable. There are no issues with the current prescription.
The patient’s prostate cancer was pathologically confirmed as small cell neuroendocrine carcinoma on 2021-12-01. Given the histologic characteristics of small cell components, the regimens used for small cell lung cancer (SCLC) are considered preferable. Therefore, the patient received both cisplatin (25mg/m2) and etoposide (100mg/m2) on days 1 to 3 for 4 cycles in the first quarter of 2022. The same regimen was restarted (etoposide at 80mg/m2) on 2023-04-20 due to a lung wedge biopsy performed on 2023-03-17 that indicated metastatic small cell neuroendocrine carcinoma. The treatment is currently ongoing.
There were no notable abnormalities found in the TPR panel and lab data from 2023-05-16. In addition, no medication reconciliation issues were identified.
[MedRec]
Upon comparing the refilled repeat prescription with patient records in PharmaCloud and HIS5, all medications were successfully integrated into the active medication list without any discrepancies.
[exam findings]
[MedRec]
[chemotherapy]
[tube feeding]
All medications currently listed on the active drug list for oral administration are suitable for enteral tube feeding.
[reconciliation]
The PhamaCloud database did not contain any records of the patient’s medical history from other healthcare facilities. No medication discrepancies were identified.
[tube feeding]
All medications currently listed for oral administration on the active medication list are suitable for enteral feeding via tube.
The patient has been a long-term patient at NTUH before seeking treatment at our institution. Currently, there are no valid repeat prescriptions issued by NTUH. No discrepancies with medication reconciliation have been identified.
[MedRec]
[radiotherapy]
[chemotherapy]
Culture results from both sputum and urine samples collected on 2023-12-29, reported on 2024-01-01, revealed mixed normal flora and less than 1000 CFU/mL, respectively. This, along with the declining CRP level, might suggest a positive response to ongoing cefepime 2000mg Q12H therapy.
Additionally, G-CSF administered since 2023-12-28 has effectively mitigated the leukopenia.
No medication discrepancies were identified during reconciliation.
[exam findings]
[MedRec]
[tube feeding]
This hospital offers Const-K 750mg, the only oral potassium supplement available. Each extended-release tablet delivers 10 mEq of potassium, equivalent to about 4.5 medium bananas. While a single banana can provide some potassium (2.2 mEq per inch, 0.9 mEq per cm), Const-K offers a concentrated and stable dose for easier dietary supplementation. For easier swallowing, the tablet can be crushed into fine particles and mixed with water.
[exam findings]
[consultation]
[radiotherapy]
[chemotherapy]
[body weight loss]
According to the weight records revealed by the TPR panel, the patient’s weight was 48kg on 2023-11-23, 37.6kg on 2023-12-13, and 37.2kg on 2023-12-27. CCRT with temozolomide QW12345 began on 2023-12-13. It can be found that the patient’s weight loss mainly occurred before temozolomide initialization. Therefore, temozolomide is less likely to be the main cause of the patient’s weight loss.
It is worth noting that the incidence of anorexia with temozolomide is 27%, nausea (49% to 53%; grades >= 3: 1% to 10%), vomiting (29% to 42%; grades >= 3: 2% to 6%), and lymphocytopenia (grades 3/4: 55%). The patient is currently receiving tube feeding. It is important to monitor the patient’s nutritional intake, observe for nausea and vomiting, and monitor CBC and WBC counts.
[lymphopenia]
The patient’s lymphocyte percentage in WBC DC consistently falls below the normal range of 20% to 45% across all available data points, both pre- and post-CCRT. This persistent lymphopenia might suggest a potential impairment in the patient’s capacity for orchestrated and specific immune responses, which could impact their ability to fight the cancer.
[exam findings]
[MedRec]
[leukopenia]
The patient’s primary medications include the cyclin-dependent kinase inhibitor palbociclib and the aromatase inhibitor letrozole. Palbociclib was initially prescribed at a daily dose of 125mg starting from late July this year, which was then reduced to 75mg daily from early August. Letrozole has been consistently administered at a daily dose of 2.5mg. The bone mineral density loss associated with the use of AI letrozole and bone metastases are being managed with zoledronic acid and calcium supplements.
Neutropenia, including grades 3 and 4, is a common observation in patients taking palbociclib. The median duration of neutropenia of grade >=3 is approximately 7 days. Cases of febrile neutropenia and neutropenic sepsis have also been reported. Neutropenia caused by palbociclib is rapidly reversible upon stopping the medication.
Our hospital currently stocks Ibrance (palbociclib) in 125mg, 100mg, and 75mg dosages. However, the patient is already on the lowest recommended dose of 75mg. Other CDK4/6 inhibitors like abemaciclib and ribociclib also have similar adverse effects of leukopenia.
According to the latest NCCN guidelines, for postmenopausal patients with ER (+), PR (+), Her2 (-) stage IV breast cancer, the recommended treatments include:
Both options involve the use of a CDK4/6 inhibitor. Given that the CT scan on 2023-12-27 showed disease regression, indicating that the current regimen is still effective in controlling the disease.
While some research suggests that G-CSF isn’t always necessary for managing neutropenia in CDK4/6 inhibitor-based treatments, it’s important to consider the differences between this and chemotherapy-induced neutropenia. Ref: Management of adverse events during cyclin-dependent kinase 4/6 (CDK4/6) inhibitor-based treatment in breast cancer. Ther Adv Med Oncol. 2018 Sep 3;10:1758835918793326.
Key Points: - CDK4/6 inhibitor-induced neutropenia (usually with palbociclib and fulvestrant) is typically less severe: - Grade 3/4 neutropenia usually resolves within 7 days. - Missing pancytopenia and lower infection rates compared to chemotherapy. - G-CSF may not be necessary. - Chemotherapy-induced neutropenia is more severe and frequent: - Grade 4 neutropenia in over 30% of patients within the first 4 cycles. - Up to 23% experience febrile neutropenia. - Mortality rate of around 5%. - CDK4/6 inhibitor-induced neutropenia shows a favorable profile: - Lower rates of both grade 4 neutropenia and febrile neutropenia compared to chemotherapy. - Neutropenia often decreases with each treatment cycle, suggesting no cumulative toxicity. - Aligns with the targeted mechanism of CDK4/6 inhibitors.
If the patient does not object, it may be possible to add testing for PIK3CA or AKT1/PTEN-activating mutations for reference in the future selection of drugs.
[MedRec]
[chemotherapy]
[chemotherapy-induced peripheral neuropathy]
Due to concerns about the developed peripheral neuropathy, oxaliplatin was not included in the FOLFOX protocol administered during this hospital stay.
Recent guidelines support the use of duloxetine for managing chemotherapy-induced peripheral neuropathy (CIPN). Both the 2020 ASCO guideline and the joint ESMO/EONS/EANO guideline recommend duloxetine as a treatment option for neuropathic pain in this setting. (Reference: Loprinzi CL, et al. J Clin Oncol 2020; 38:3325)
For adult patients with CIPN, duloxetine is typically started at 30mg orally once daily for the first week, then increased to 60mg once daily thereafter. This dosing recommendation is based on a large, randomized clinical trial by Smith et al. (Reference: Smith EM, et al. JAMA 2013;309(13):1359-67)
There is Cymbalta (duloxetine 30mg capsules) readily available within our stock to be prescribed.
[exam findings]
[MedRec]
Based on the findings of the upright CXR performed on 2023-12-24, which showed cardiomegaly, focal consolidation in the left upper and retrocardiac lung fields, and blunted left costophrenic angle, empirical Sintrix (ceftriaxone) was initiated while culture results are pending.
The patient’s persistent hypertension (170/75 mmHg since admission) could suggest exploring a target systolic blood pressure (SPB) of 150 mmHg. Amlodipine 5mg QD and hydralazine 50mg PRNBID have been prescribed for blood pressure control.
[lab data]
2023-11-13 HBV-DNA-PCR Target Not Detected IU/mL
2023-11-08 HBsAg Nonreactive
2023-11-08 HBsAg (Value) 0.34 S/CO
2023-11-08 Anti-HBs 538.50 mIU/mL
2023-11-08 Anti-HBc Reactive
2023-11-08 Anti-HBc-Value 6.16 S/CO
2023-11-08 Anti-HCV Nonreactive
2023-11-08 Anti-HCV Value 0.11 S/CO
[exam findings]
[MedRec]
[immunochemotherapy]
[reconciliation]
Following lab findings on 2023-12-25 (CRP 11.5 mg/dL and erect CXR demonstrating right lower lung consolidation and blunted costophrenic angles), Brosym (cefoperazone/sulbactam) was initiated. The patient’s fever has favorably responded, decreasing to 37’C as of 2023-12-26. No medication discrepancies were noted.
This patient is currently undergoing the R-COP regimen and is also taking Vemlidy (tenofovir alafenamide) due to being anti-HBc positive. The patient’s vital signs are stable, and no discrepancies in medication have been identified.
[exam findings]
[MedRec]
[tube feeding]
Concor 5mg administration via Simple Suspension Method (SSM):
For patients requiring enteral nutrition, dissolve the Concor 5mg tablet using the SSM. This efficient method involves:
Benefits of SSM:
[MedRec]
[chemotherapy]
2023-12-05 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)
2023-11-21 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)
2023-11-07 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)
2023-10-24 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)
2023-10-03 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)
2023-09-19 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2860mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)
2023-08-17 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2860mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)
2023-07-12 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 430mg NS 250mL 2h4 + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (FOLFIRI Q2W. Iri, Lv and Fu 20% off)
2023-06-26 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 430mg NS 250mL 2h4 + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (FOLFIRI Q2W. Iri, Lv and Fu 20% off)
2022-07-05 - (FOLFOXIRI)
2022-06-21 - (FOLFOXIRI)
2022-06-07 - (FOLFOXIRI)
2022-05-24 - (FOLFOXIRI)
2022-05-10 - (FOLFOXIRI)
2022-04-12 - (FOLFOXIRI)
2022-03-22 - (FOLFOXIRI)
2022-03-08 - (cetuximab + FOLFOXIRI)
2022-02-22 - (cetuximab + FOLFOXIRI)
2022-02-08 - (cetuximab + FOLFOXIRI)
2022-01-18 - (cetuximab + FOLFOXIRI)
2022-04-04 - (cetuximab + FOLFOXIRI)
2021-12-07 - (cetuximab + FOLFOXIRI)
2021-11-02 - (Oxa)
2021-10-05 - (Oxa)
2021-09-14 - (Oxa)
2021-08-24 - (Oxa)
2021-08-03 - (Oxa)
2021-07-13 - (Oxa)
2021-06-09 - (Oxa)
2021-05-18 - (Oxa)
2021-04-27 - (Oxa)
2021-04-06 - (Oxa)
2021-03-16 - (Oxa)
2021-02-23 - (Oxa)
2021-02-01 - (FOLFOX)
2020-07-20 - (Avastin + FOLFIRI)
2020-07-06 - (Avastin + FOLFIRI)
2020-06-22 - (Avastin + FOLFIRI)
2020-06-08 - (Avastin + FOLFIRI)
2020-05-25 - (Avastin + FOLFIRI)
2020-05-06 - (Avastin + FOLFIRI)
2020-04-15 - (Avastin + FOLFIRI)
2020-04-01 - (Avastin + FOLFIRI)
2020-03-20 - (Avastin + FOLFIRI)
[reconciliation]
It is noted that not all of the drugs prescribed on 2023-10-24 by our endocrinologistare currently reflected on the active medication list. To prevent any potential misunderstandings and to ensure timely access to necessary medications, it might be beneficial to double-check and update the list if needed.
Our endocrinologist issued a repeat prescription for Docone (dexamethasone), Florinef (fludrocortisone), Crestor (rosuvastatin), and Lipanthyl Supra (fenofibrate), all of which are currently in use, with no medication reconciliation problems found.
[chemotherapy]
Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma - 2023-12-21 - https://www.uptodate.com/contents/image?imageKey=ONC%2F101205
Cycle length: 28 days.
Regimen
Pretreatment considerations:
Monitoring parameters:
Suggested dose modifications for toxicity:
[hyperuricemia]
Hyperuricemia was detected on 2023-12-22 with a serum uric acid level of 11.7 mg/dL. Two potential treatment options for this elevated uric acid level might be considered:
[anemia]
The patient’s HGB level has been consistently below normal since admission. The lowest level was observed on 2023-12-21. Bortezomib was administered on 2023-12-20 and is associated with anemia in 12-23% of patients (grades 3-6). It is possible that bortezomib exacerbated the existing anemia.
The patient should receive red blood cell transfusions as clinically indicated.
[VTd regimen administration schedule]
VTd regimen is supposed to be administered as following:
Bortezomib and dexamethasone were administered on 2023-12-20 (C1D1). However, thalidomide 100 mg daily was started ahead of schedule on 2023-12-14. To align with the administration cycle (28 days) and discontinue thalidomide on C1D22, it should be stopped on 2024-01-10.
[CMV viral load detected]
As of 2023-12-18, the CMV viral load was measured at 190 IU/mL. Depending on the clinical context and your concerns about this level, valganciclovir 900mg BID could be a potential treatment option.
[exam findings]
[MedRec]
[immunochemotherapy]
Serum uric acid levels sometimes exceed the normal range, and Feburic (febuxostat) has been prescribed for treatment. No medication discrepancies have been identified.
[reconciliation]
The patient’s PharmaCloud records are not currently available. However, after reviewing HIS5, no medication discrepancies were found.
[leukopenia]
Leukopenia was noted in early Oct, approximately 2 weeks after his last R-CHOP treatment (3rd dose) on 2023-09-19. On 2023-10-04, the patient was started on G-CSF (filgrastim) 300mg SC QD. A slight improvement in WBC count was observed on 2023-10-06. There is no problem with the treatment.
2023-10-06 WBC 0.85 x10^3/uL
2023-10-04 WBC 0.65 x10^3/uL
2023-09-26 WBC 3.37 x10^3/uL
2023-09-18 WBC 4.63 x10^3/uL
[lab data]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemoimmunotherapy]
Romiplate (romiplostim 250ug) ST SC
[atrial fibrillation]
Multaq (dronedarone) and Lixiana (edoxaban) were prescribed for the patient’s atrial fibrillation (AF) in a repeat prescription issued by our cardiologist on 2023-09-18. These medications are not currently being used. Please confirm whether there is a contraindicated condition or if the medications are no longer necessary.
Our cardiologist prescribed Urief (silodosin), spironolactone, Multaq (dronedarone), Lixiana (edoxaban), Atozet (ezetimibe, atorvastatin), Wecoli (bethanechol), and Nirandil (nicorandil) on 2023-06-28, and these drugs are correctly included in the active formulary, so no reconciliation issues were found.
[exam findings]
[immunochemotherapy]
[mucositis]
Combining the suggestions from both the MASCC/ISOO 2020 guidelines and the JCO Oncology Practice, here’s a pointwise summary of the recommendations:
Preventive Measures
General Management
Pain Management and Symptom Relief
Hospital Admission Considerations
Diet and Oral Care
Use of Specific Agents
Ref:
Management of Cancer Therapy - Associated Oral Mucositis. JCO Oncology Practice. 2020;16(3):103-109. doi:10.1200/JOP.19.00652
MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2020;126(19):4423-4431. doi:10.1002/cncr.33100
[lab data]
2023-08-04 HBV DNA-PCR (quantative) Target Not Detected IU/mL
2023-08-04 Anti-HCV (NM) Negative
2023-08-04 Anti-HCV Value (NM) 0.044
2023-08-04 Anti-HBc (NM) Negative
2023-08-04 Anti-HBc Value (NM) 1.110
2023-08-04 Anti-HBs (NM) Positive
2023-08-04 Anti-HBs Value (NM) 45.800 mIU/mL
2023-08-04 HBsAg (NM) Negative
2023-08-04 HBsAg Value (NM) 0.362
2023-08-04 HBsAg Nonreactive
2023-08-04 HBsAg (Value) 0.27 S/CO
2023-08-04 Anti-HBs 45.52 mIU/mL
2023-08-04 Anti-HBc Nonreactive
2023-08-04 Anti-HBc Value 0.48 S/CO
2023-08-04 Anti-HCV Nonreactive
2023-08-04 Anti-HCV Value 0.22 S/CO
[exam findings]
[MedRec]
[surgical operation]
[immunochemotherapy]
[acute respiratory distress syndrome, ARDS]
Treatment course
ARDS and pembrolizumab considerations
Current status and recommendation
Ref:
[exam findings]
[MedRec]
[chemotherapy]
On 2023-12-18, the patient exhibited pancytopenia, including severe grade 3 anemia. Blood product transfusion was administered the same day.
Low levels of serum sodium, potassium, calcium, magnesium, and albumin were also detected. Taita No.5 electrolyte solution, KCl, and MgSO4 were prescribed.
A positive stool occult blood test (1+) was identified on 2023-12-17. The patient is currently receiving Panzolec (pantoprazole) and Hemoclot (tranexamic acid).
Medication reconciliation found no discrepancies.
[lab data]
2023-11-02 Ferritin 667.6 ng/mL
2023-10-26 FLT3-D835 (bone marrow) Undetectable
2023-10-25 MPO stain Positive (3+)
2023-10-25 ANAE stain Negtive
2023-10-25 CAE stain Positive
2023-10-18 NPM1 (qualitative)(BM) Undetectable
2023-10-18 FLT3/ITD (bone marrow) Undetectable
2023-10-18 JAK2-single site (BM) Undetectable
2023-10-18 BCR/abl (BM) PhiladChr (qual) Undetectable
2023-10-16 Von willebrand factor 100.8 %
2023-10-13 HBV-DNA-PCR Target Not Detected IU/mL
2023-10-12 TSH (NM) 2.348 uIU/ml
2023-10-12 T3 (NM) 95.975 ng/dl
2023-10-12 Free T4 (NM) 1.190 ng/dl
2023-10-13 HBV-DNA-PCR Target Not Detected IU/mL
2023-10-12 HBsAg Nonreactive
2023-10-12 HBsAg (Value) 0.41 S/CO
2023-10-12 Anti-HBc Reactive
2023-10-12 Anti-HBc-Value 4.57 S/CO
2023-10-12 Anti-HCV Nonreactive
2023-10-12 Anti-HCV Value 0.10 S/CO
[exam findings]
[MedRec]
[chemotherapy]
Acute myeloid leukemia: Induction therapy in medically-fit adults - 2023-10-16 - https://www.uptodate.com/contents/acute-myeloid-leukemia-induction-therapy-in-medically-fit-adults
(not posted yet)
2023-11-01 WBC 2.15 x10^3/uL
2023-10-28 WBC 1.40 x10^3/uL
2023-10-27 WBC 1.01 x10^3/uL
2023-10-25 WBC 0.96 x10^3/uL
2023-10-23 WBC 0.87 x10^3/uL
2023-10-21 WBC 1.07 x10^3/uL
2023-10-19 WBC 1.82 x10^3/uL
2023-10-16 WBC 3.49 x10^3/uL
2023-10-12 WBC 25.68 x10^3/uL
2023-10-09 WBC 30.61 x10^3/uL
2023-11-01 HGB 7.7 g/dL
2023-10-28 HGB 8.0 g/dL
2023-10-27 HGB 8.1 g/dL
2023-10-25 HGB 8.7 g/dL
2023-10-23 HGB 7.6 g/dL
2023-10-21 HGB 8.1 g/dL
2023-10-19 HGB 7.7 g/dL
2023-10-16 HGB 8.9 g/dL
2023-10-12 HGB 10.3 g/dL
2023-10-09 HGB 9.8 g/dL
2023-11-01 PLT 6 10^3/uL
2023-10-28 PLT 40 10^3/uL
2023-10-27 PLT 56 10^3/uL
2023-10-25 PLT 91 10^3/uL
2023-10-23 PLT 17 10^3/uL
2023-10-21 PLT 32 10^3/uL
2023-10-19 PLT 9 10^3/uL
2023-10-16 PLT 48 10^3/uL
2023-10-12 PLT 148 10^3/uL
2023-10-09 PLT 11 10^3/uL
preparing blood on 2023-11-29, -11-12, -10-28, -10-23, -10-19, -10-11
[anemia]
Pre-existing anemia was identified in this patient prior to the initiation of the standard 7+3 regimen on 2023-10-13. Following completion of three cycles (one 7+3 and two 5+2), it is anticipated to possibly lead to pancytopenia within three weeks. Therefore, RBC transfusions should be provided as needed to manage the patient’s anemia.
[WBC nadir 870/uL on 2023-10-23, no blast found after 2023-10-16]
In AML patients undergoing the 7+3 induction chemotherapy regimen, a nadir leukocyte level, specifically below 200/uL, was linked to a higher probability of achieving complete remission (CR). This indicates that patients who experience a more significant decrease in their leukocyte levels during chemotherapy tend to have a more favorable prognosis in terms of reaching CR. Ref: Association of leukocyte nadir with complete remission in Indonesian acute myeloid leukemia patients undergoing 7+3 remission induction chemotherapy. F1000Res. 2022 May 5;11:495. doi: 10.12688/f1000research.110320.2. PMID: 35721596; PMCID: PMC9194516.
The patient started the standard 7+3 regimen on 2023-10-13 and recent lab data suggest that the nadir was reached on 2023-10-23 with a WBC of 960/uL. Based on the aforementioned study, this correlates with a reduced chance of achieving CR.
However, looking at the percentage of blasts in the WBC differential count, no blasts were detected after 2023-10-16. This indicates at least a short-term effect of the treatment.
[pancytopenia]
The onset of pancytopenia is an expected consequence following the initiation of the standard 7+3 chemotherapy regimen on 2023-10-13. In response to this, the patient received a transfusion of 2 units of leukocyte-poor red blood cells (LPRBC) and 2 units of leukocyte-reduced platelets (LRP) on 2023-10-19, a standard procedure in such cases. This intervention proceeded without any complications.
2023-10-19 WBC 1.82 x10^3/uL
2023-10-16 WBC 3.49 x10^3/uL
2023-10-12 WBC 25.68 x10^3/uL
2023-10-19 HGB 7.7 g/dL
2023-10-16 HGB 8.9 g/dL
2023-10-12 HGB 10.3 g/dL
2023-10-19 PLT 9 *10^3/uL
2023-10-16 PLT 48 *10^3/uL
2023-10-12 PLT 148 *10^3/uL
[von Willebrand factor (VWF)]
The von Willebrand factor (VWF) test results showed normal on 2023-10-16, it means that the amount of VWF in the blood is within the normal range. However, this does not necessarily mean that the person does not have von Willebrand disease (VWD).
There are several types of VWD, and some people with VWD may have normal VWF levels. For example, people with type 2N VWD have normal levels of VWF antigen and VWF activity, but the VWF molecules are not functioning properly.
Other possible reasons for normal VWF levels in a person with VWD include:
If a person with normal VWF levels has a history of bleeding or a family history of VWD, they may still need further testing to rule out VWD. This may include tests such as the ristocetin cofactor (RCo) assay and the VWF multimer analysis.
[leukopenia]
There is no identified history of AML and/or MDS from PharmaCloud or HIS5 records, suggesting this is a newly diagnosed de novo AML in this patient.
The patient was started on the standard 7+3 cytarabine/idarubicin chemotherapy regimen on 2023-10-13. The patient’s white blood cell count (WBC) was high on 2023-10-09, but quickly decreased to 3.49K/uL on 2023-10-16. While a WBC of 3.49K/uL is considered mild leukocytopenia, a decrease in all three types of blood cells (pancytopenia) is expected within the first three weeks after starting the 7+3 regimen.
[hypertension]
Per the records, the patient visited the family medicine department on 2023-10-09 and has a history of hypertension, managed with atenolol, losartan, and red yeast rice. Although no antihypertensive medications are currently listed as active, the latest blood pressure reading of 130/63 mmHg (taken on 10/16 at 08:39) does not indicate significant hypertension. Therefore, there’s no immediate necessity to reintroduce antihypertensive agents. However, it’s advisable to continue monitoring blood pressure to determine if there’s a need to resume these medications.
[risk stratification]
If AML is strongly suspected, genetic analysis is recommended for risk stratification and to determine the presence of actionable mutations (such as FLT3), which may warrant the consideration of additional treatments like midostaurin or potentially quizartinib.
[antiviral prophylaxis]
The American Society of Clinical Oncology and the Infectious Disease Society of America recommend that severely neutropenic patients undergoing intensive chemotherapy receive prophylactic antibacterial and antifungal therapy and that patients who are seropositive for hepatitis B core antibody or herpes simplex virus with leukemia receive antiviral prophylaxis. Ref: Antimicrobial Prophylaxis for Adult Patients With Cancer-Related Immunosuppression: ASCO and IDSA Clinical Practice Guideline Update. J Clin Oncol. 2018 Oct 20;36(30):3043-3054. doi: 10.1200/JCO.18.00374. Epub 2018 Sep 4. PMID: 30179565.
Vemlidy (tenofovir alafenamide) is currently used to reduce the risk of reactivation of HBV infection. However, laboratory results for herpes simplex virus are not yet available.
[prophylaxis of bacterial infection in neutropenia]
Severe and prolonged cytopenias are a common occurrence with intensive remission induction therapy, as the patient is likely to develop pancytopenia within three weeks of receiving the standard 7+3 regimen. Transfusions of red blood cells and platelets should be given as needed. However, the routine use of granulocyte colony-stimulating factor (G-CSF; filgrastim) and other myeloid growth factors is not usually recommended.
High-risk patients of chemotherapy-induced neutropenia are those who are expected to be neutropenic (ANC < 500 cells/uL) for > 7 days.
Guidelines from the American Society of Clinical Oncology (ASCO) and Infectious Diseases Society of America (IDSA) recommend consideration of fluoroquinolone prophylaxis in patients at high risk for profound prolonged neutropenia (anticipated ANC <= 100 cells/uL for > 7 days)
Consensus-based National Comprehensive Cancer Network (NCCN) guidelines suggest strong consideration of fluoroquinolone prophylaxis for high-risk patients: those undergoing allogeneic HCT, neutropenic patients receiving induction chemotherapy for acute leukemia, and any patient in whom the duration of anticipated neutropenia is > 10 days.
Ciprofloxacin and levofloxacin have been studied most extensively. Ciprofloxacin has greater in vitro activity than levofloxacin against P. aeruginosa, but levofloxacin has greater in vitro activity against gram-positive bacteria (eg, alpha-hemolytic streptococci) and is given only once daily compared with twice daily for ciprofloxacin.
[prophylaxis of invasive fungal infection in neutropenia]
Continuing from the previous pharmacist’s note:
[chemotherapy dose to remain the same for patient with normal lab results]
For patients receive standard 7+3 regimen, it is recommended to assess for comorbidities that may affect the ability to tolerate intensive therapy.
The patient’s liver and kidney function tests on 2023-10-16 were normal. His 2D transthoracic echocardiography on the same day showed an M-mode Teichholz measurement of 66, adequate left ventricular systolic function, and normal resting wall motion. There is no evidence of tumor lysis syndrome (no serum phosphate was tested). Therefore, there is no need to adjust the patient’s current standard 7+3 chemotherapy dose.
2023-10-16 AST 14 U/L
2023-10-16 ALT 21 U/L
2023-10-16 BUN 18 mg/dL
2023-10-16 Creatinine 0.70 mg/dL
2023-10-16 eGFR 117.82 ml/min/1.73m^2
2023-10-16 Bilirubin total 0.60 mg/dL
2023-10-16 Bilirubin direct 0.08 mg/dL
2023-10-16 DBI/TBI 13.33 %
2023-10-16 K(Potassium) 3.6 mmol/L
2023-10-16 Uric Acid 6.3 mg/dL
2023-10-16 Ca (Calcium) 2.08 mmol/L
[nadir response assessment]
A bone marrow biopsy is done at the lowest point of the patient’s blood counts (hematologic nadir), which is usually between days 14 and 22 of treatment. However, for patients who are not receiving midostaurin (a drug used to treat AML), the nadir assessment does not have to be done on day 22.
Further treatment decisions are based on the results of the bone marrow biopsy:
If the results of the bone marrow biopsy are unclear, another bone marrow biopsy should be done 5 to 7 days later.
[MedRec]
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
According to the eGFR laboratory data since Nov, the patient’s renal function has decreased in the past two weeks. The dose of carboplatin has been adjusted accordingly (2023-12-14 425mg <- 2023-11-16 580mg), while the dose of paclitaxel does not require adjustment due to the change in renal function.
Furthermore, no adjustments are needed for the drugs listed on the active medication list other than those used in chemotherapy, based on the renal function test results from 2023-12-13.
[lab data]
2023-12-13 Influenza A Ag Negative
2023-12-13 Influenza B Ag Negative
2023-12-04 Rubella IgM Negative Index
2023-12-04 Rubella IgM Value 0.05
2023-12-04 Measles virus IgM Ab Negative Ratio
2023-12-04 MeaslesIgM Value 0.1 Ratio
2023-12-04 Mumps Virus IgG Positive AU/mL
2023-12-04 Mumps Virus IgGValue >300.0 AU/mL
2023-12-04 Mumps Virus IgM Negative Index
2023-12-04 Mumps IgM Value <0.5 Index
2023-11-27 Anti-HBs 13.70 mIU/mL
2023-11-27 Anti-HCV Nonreactive
2023-11-27 Anti-HCV Value 0.12 S/CO
2023-11-27 HBsAg Nonreactive
2023-11-27 HBsAg (Value) 0.37 S/CO
2023-11-27 Anti-HAV IgM Nonreactive
2023-11-27 Anti-HAV IgM Value 0.20 S/CO
2023-11-27 Anti-HAV IgG Reactive
2023-11-27 Anti-HAV IgG Value 9.77 S/CO
[MedRec]
[exam findings]
[MedRec]
2023-12-13 ~ 2023-12-14 POMR Family Medicine Ye JiaZe
2023-11-24 ~ 2023-12-08 POMR Hemato-Oncology Gao WeiYao
2023-11-24 VS Note on Admission Day
2021-11-06 ~ 2021-11-19 POMR Urology
[enhancing patient care through shared medical records from Far Eastern Memorial Hospital]
Per the PharmaCloud database, the patient was diagnosed with “Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT-lymphoma)” at Far Eastern Memorial Hospital, with his last visit on 2023-08-24. The patient should be requested to provide the examination results and treatment details from that hospital to enable our medica team a more comprehensive consideration of the current situation.
[optimizing calcitonin Use for hypercalcemia management]
The patient, who has hypoalbuminemia, shows a corrected calcium level of 3.1 mmol/L (12.4 mg/dL) and is currently receiving Miacalcic (calcitonin) at 100 IU SC Q6H.
2023-11-27 Ca (Calcium) 2.91 mmol/L
2023-11-26 Ca (Calcium) 3.03 mmol/L
2023-11-24 Ca (Calcium) 3.08 mmol/L
2023-11-27 Albumin (BCG) 3.0 g/dL
2023-11-24 Albumin (BCG) 3.2 g/dL
For severe hypercalcemia, the maintenance dose of calcitonin can be up to 8 units/kg Q6H to Q12H, starting with an initial dose of 4 units/kg Q12H. Since the current administration of 100 IU Q6H is below the recommended dosage, this may extend the duration of therapy. It’s advisable to limit calcitonin therapy to a period of 24 to 48 hours to avoid tachyphylaxis.
Given that the serum calcium level has not exceeded 3.5 mmol/L (14 mg/dL) and is trending downwards, the combined use of calcitonin with bisphosphonates for a long-term effect may not be essential.
[basal insulin initiation for consistent hyperglycemia]
All recorded blood glucose levels in the TPR panel fall between 230 and 380 mg/dL during this hospitalization, frequently exceeding 300 mg/dL, despite the current use of Insulin Actrapid, NovoRapid, and Trajenta. Therefore, it is advisable to introduce basal insulin (a long-acting type) starting with a daily dose of 2 units, with evaluations every other day to determine if further adjustments are necessary.
[replacing D5W with NS in hyperglycemic hydration plan]
Given the patient’s obvious hyperglycemia, it is advisable to switch from D5W to NS for hydration purposes.
[evaluating causes of hypercalcemia: beyond hyperthyroidism]
The lab results showed no elevation in TSH, Free-T4, or T3, suggesting that hyperthyroidism is an unlikely cause of the hypercalcemia. Could osteolytic bone metastases and local cytokines be contributing factors?
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[thrombocytopenia]
Thrombocytopenia was first observed in April 2023 and has not yet returned to the lower limit of normal range (150K/uL). Since December, platelet counts have been consistently below 50K/uL. Bevacizumab was started in August 2023.
Both bevacizumab and fluorouracil are known to cause thrombocytopenia, with bevacizumab showing a higher incidence rate of up to 58% (grades 3/4: 20% to 40%).
According to UpToDate recommendations, in cases of hemorrhage caused by bevacizumab, such as hemoptysis (recent history of >= 2.5 mL), bevacizumab should be withheld. For Grade 3 or 4 hemorrhage, bevacizumab should be discontinued. As there has been no recent documentation of hemorrhage found in the medical records, it may not be necessary to temporarily stop the use of bevacizumab at this time.
Blood transfusion has been scheduled according to the progress note.
The patient has only visit our hospital in the last 3 months according to the PharmaCloud database, our gastroenterologist prescribed Baraclude (entecavir) for she is a carrier of viral hepatitis B. Baraclude is in the active medication list, no reconciliation issues found.
On 2023-06-18, the patient’s fecal occult blood test was 2+, indicating a possible GI bleeding. On this date, the patient has been prescribed lansoprazole and tranexamic acid. The prescription for lansoprazole is set to expire on 2023-06-21. It would be beneficial to evaluate whether signs of bleeding persist to decide whether to continue the PPI.
[MedRec]
[surgical operation]
[chemotherapy]
The PharmaCloud records show that this patient recently refilled his prescription for metformin and Sevikar (amlodipine, olmesartan) on 2023-12-03 for a 28-day supply. These drugs have been included in the active medication list.
Zytiga (abiraterone) has been in use since early 2021 and continues to be part of the patient’s treatment regimen. Androcur (cyproterone) was administered from 2019-10 to 2020-01, with two doses of Leuplin (leuprorelin) given on 2019-10-01 and 2019-10-31 prior to the initiation of Zytiga.
It is advisable that patients receiving abiraterone should also receive a gonadotropin-releasing hormone (GnRH) analog concurrently (or have had a bilateral orchiectomy).
[exam findings]
[consultation]
[chemotherapy]
The leukopenia observed on 2023-08-24 (WBC 1.5K/uL) was likely a result of the paclitaxel and carboplatin administered on 2023-08-11. Following a 3-day course of G-CSF from 2023-08-24 to 2023-08-26, no further instances of leukopenia have been observed.
A new cycle of the treatment regimen was initiated on 2023-09-01, and prophylactic G-CSF is scheduled for 2023-09-06, 2023-09-07, and 2023-09-08.
2023-08-31 WBC 3.20 x10^3/uL
2023-08-24 WBC 1.50 x10^3/uL
2023-08-08 WBC 5.12 x10^3/uL
2023-07-25 WBC 3.29 x10^3/uL
2023-07-17 WBC 5.76 x10^3/uL
2023-07-12 WBC 4.41 x10^3/uL
2023-07-03 WBC 1.64 x10^3/uL
2023-06-28 WBC 1.69 x10^3/uL
2023-06-19 WBC 2.08 x10^3/uL
2023-06-12 WBC 2.72 x10^3/uL
2023-06-05 WBC 4.78 x10^3/uL
2023-05-30 WBC 3.99 x10^3/uL
2023-05-22 WBC 4.35 x10^3/uL
2023-05-15 WBC 4.67 x10^3/uL
2023-05-12 WBC 4.78 x10^3/uL
2023-05-09 WBC 8.17 x10^3/uL
2023-05-09 WBC 13.14 x10^3/uL
2023-04-19 WBC 5.07 x10^3/uL
2023-04-03 WBC 5.23 x10^3/uL
2023-03-28 WBC 13.97 x10^3/uL
2023-03-23 WBC 7.35 x10^3/uL
2023-03-03 WBC 5.22 x10^3/uL
The Eltroxin (levothyroxine) prescribed by our endocrinologist on 2023-08-01 is currently listed in the active medications without any reconciliation discrepancies identified.
Our endocrinologist wrote a repeat prescription for Eltroxin (levothyroxine) on 2023-08-01 and the drug is included in the formulary with no reconciliation issue identified.
[reconciliation]
The patient was seen by our urologist on 2023-07-12 who prescribed Cero (cefaclor 250mg) 2# TID and Celebrex (celecoxib 200mg) 1# QD for a period of 7 days to treat suspected UTI infection or catheter-related discomfort. These medications are not currently on the active medication list, so it’s advisable to confirm resolution of these symptoms.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[leukopenia, diarrhea]
Review of lab data from HIS5 reveals that the last documented episode of leukopenia occurred on 2023-10-04, exceeding two months ago. Serial WBC counts demonstrate a period of low values approximately one week after docetaxel administration. However, recent data is insufficient to confirm or rule out the current presence of leukopenia.
This patient is currently taking Nolvadex (tamoxifen citrate 10mg/tablet) 1# BID, a medication that is generally not linked to leukopenia.
Moreover, the lab results indicate increased levels of myelocytes and metamyelocytes. It might be important to investigate further to determine if these findings have clinical significance.
No significant episodes of diarrhea were found documented in the recent medical history.
[leukopenia]
The patient underwent 4 rounds of liposome doxorubicin and cyclophosphamide treatment on 2023-05-03, 2023-05-25, 2023-06-15, and 2023-07-06 without any signs of leukopenia.
However, a week following the initial dose of docetaxel on 2023-08-04, leukopenia was detected. Consequently, Granocyte (lenograstim 250ug) was administered the same day.
Docetaxel is associated with a high incidence of leukopenia. (UpToDate: 84% to 99%; grades 3/4: 49%; grade 4: 32% to 44%)
The patient received a second dose of docetaxel on 2023-08-17. Prophylactic G-CSF is scheduled for 2023-08-22 and 2023-08-23. Currently, there’s no indication of newly emerging leukopenia.
[lab data]
2023-11-28 HLA A-high 11:01
2023-11-28 HLA A-high 24:02
2023-11-28 HLA B-high 27:04
2023-11-28 HLA B-high 35:01
2023-11-28 HLA C-high 08:01
2023-11-28 HLA C-high 12:02
2023-11-28 HLA DQ-high 03:01
2023-11-28 HLA DQ-high 03:03
2023-11-28 HLA DR-high 12:01
2023-11-28 HLA DR-high 12:02
2023-09-13 FLT3-D835 (bone marrow) Undetectable
2023-09-11 CD2 NA
2023-09-11 CD3 3.4
2023-09-11 CD4 NA
2023-09-11 CD5 1.3
2023-09-11 CD7 98.6
2023-09-11 CD8 NA
2023-09-11 CD10 2.4
2023-09-11 CD11b 32.8
2023-09-11 CD13 94.7
2023-09-11 CD14 1.2
2023-09-11 CD15 NA
2023-09-11 CD16 0.76
2023-09-11 CD19 6.2
2023-09-11 CD19/kappa NA
2023-09-11 CD19/Lambda NA
2023-09-11 CD20 1.8
2023-09-11 CD23 NA
2023-09-11 CD25 NA
2023-09-11 CD33 85.2
2023-09-11 CD34 90.6
2023-09-11 CD38 NA
2023-09-11 CD56 0.4
2023-09-11 CD103 NA
2023-09-11 CD117 98.5
2023-09-11 CD138 NA
2023-09-11 FMC7 NA
2023-09-11 HLA-DR 99.1
2023-09-11 MPO NA
2023-09-11 TdT NA
2023-09-11 FLT3/ITD (bone marrow) Presence of mutation
2023-09-11 NPM1 (bone marrow) Undetectable
2023-09-11 LDH 276 U/L
2023-09-09 LDH 513 U/L
2023-09-05 LDH 2394 U/L
2023-09-04 HBsAg Nonreactive
2023-09-04 HBsAg (Value) 0.57 S/CO
2023-09-04 Anti-HBc Nonreactive
2023-09-04 Anti-HBc-Value 0.43 S/CO
2023-09-04 Anti-HCV Nonreactive
2023-09-04 Anti-HCV Value 0.14 S/CO
2023-09-03 LDH 1578 U/L
2023-08-31 Uric Acid 9.2 mg/dL
2023-08-31 LDH 1428 U/L
2023-08-31 WBC 351.74 x10^3/uL
2023-08-31 HGB 8.4 g/dL
2023-08-31 PLT 33 x10^3/uL
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[restarting posaconazole after discontinuation]
If posaconazole has been discontinued for several days (considered as washed out), it’s recommended to reintroduce the drug with a loading dose, specifically, 300 mg BID for two doses, then switch to a maintenance dose of 300 mg QD.
[leukopenia]
The patient was administered her initial dose of the cytarabine/daunorubicin (7+3) regimen on 2023-09-04. A week later, on 2023-09-11, her WBC count reached its lowest point at 0.84K/uL, after which an upward trend was noted.
2023-09-13 WBC 1.23 x10^3/uL 2023-09-11 WBC 0.84 x10^3/uL * 2023-09-10 WBC 1.02 x10^3/uL 2023-09-09 WBC 1.05 x10^3/uL 2023-09-08 WBC 1.09 x10^3/uL 2023-09-07 WBC 1.69 x10^3/uL 2023-09-06 WBC 8.35 x10^3/uL 2023-09-06 WBC 24.86 x10^3/uL 2023-09-05 WBC 247.70 x10^3/uL 2023-09-04 WBC 355.71 x10^3/uL 2023-09-03 WBC 366.64 x10^3/uL 2023-09-02 WBC 370.59 x10^3/uL 2023-09-02 WBC 361.09 x10^3/uL 2023-09-01 WBC 335.15 x10^3/uL
[thrombocytopenia]
Prior to receiving her first dose of the cytarabine/daunorubicin (7+3) regimen on 2023-09-04, the patient was already in a state of thrombocytopenia. Following the administration of chemotherapy, her platelet count (PLT) continued to decline, reaching 23K/uL on 2023-09-13, the day a blood transfusion was performed. Blood transfusions were also administered on the following dates: 2023-08-31, 2023-09-04, and 2023-09-08.
2023-09-13 PLT 23 x10^3/uL * 2023-09-11 PLT 54 x10^3/uL
2023-09-10 PLT 83 x10^3/uL
2023-09-09 PLT 124 x10^3/uL
2023-09-08 PLT 29 x10^3/uL
2023-09-07 PLT 52 x10^3/uL
2023-09-06 PLT 102 x10^3/uL
2023-09-06 PLT 125 x10^3/uL
2023-09-05 PLT 48 x10^3/uL
2023-09-04 PLT 69 x10^3/uL
2023-09-03 PLT 79 x10^3/uL
2023-09-02 PLT 75 x10^3/uL
2023-09-02 PLT 102 x10^3/uL
2023-09-01 PLT 111 x10^3/uL
For this admission, the patient was initially admitted through the emergency department and this is her first time seeking medical care at this hospital. There are no records available from PharmaCloud and no medication reconciliation issues have been identified.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[exam findings]
[MedRec]
[consultation]
[immunochemotherapy]
Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma - 2023-12-01 - https://www.uptodate.com/contents/image?imageKey=ONC%2F101205
Cycle length: 28 days.
Regimen
Pretreatment considerations:
Bortezomib - 2023-11-24 - https://www.uptodate.com/contents/bortezomib-drug-information
[thrombocytopenia]
The C1D15 dose of Velcade (bortezomib) in the VTd regimen was administered on 2023-12-07. As mentioned in the pharmacist’s note from 2023-12-04, the severe thrombocytopenia observed may not be entirely due to the VTd regimen.
Severe thrombocytopenia, with platelet counts falling below 30K to 50K/uL, significantly increases the risk of bleeding and often necessitates treatment. However, the relationship between platelet count and bleeding risk can vary depending on the underlying condition and may be unpredictable. Therefore, platelet product transfusion may be required in this situation.
[thrombocytopenia]
Severe thrombocytopenia emerged in mid and late Nov, necessitating multiple blood transfusions.
The initial session of the VTd regimen was given on 2023-11-23. Notably, the thrombocytopenia episode was present even prior to this treatment. Anemia and thrombocytopenia are frequent complications in multiple myeloma (MM) patients (Ref: Patients With Multiple Myeloma Have a Disbalanced Whole Blood Thrombin Generation Profile. Front Cardiovasc Med. 2022 Jun 27;9:919495. doi: 10.3389/fcvm.2022.919495. PMID: 35833182; PMCID: PMC9271700). The thrombocytopenia should not be solely attributed to the use of bortezomib.
[antiviral prophylaxis key to reducing HZ]
Bortezomib therapy may be associated with an increased risk of herpes zoster and infections not related to neutropenia. It is recommended that antiviral prophylaxis (eg, acyclovir 400 mg orally twice a day) should be administered to all patients receiving VTd. Some clinicians also administer trimethoprim-sulfamethoxazole double strength once daily on QW135 during treatment. Primary prophylaxis with G-CSF is not indicated.
[diagnosis] - 2023-04-18 admission note
[past history] - 2023-04-18 admission note
[allergy]
Demerol 50 mg/1 mL/amp (Meperidine):anaphylactic shock
[family history]
Father:DM No cancer, CVA, CAD history in her family
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
Granocyte (lenograstim 250ug) CGRAN01
WBC
VDC/IE (vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide) - Bone Cancer - Version 3.2023 - 2023-04-04 - https://www.nccn.org/professionals/physician_gls/pdf/bone.pdf - BONE-B, 2 OF 6, p27
Treatment for Localized Disease, Neoadjuvant chemotherapy - Treatment of Ewing sarcoma - 2023-06-20 - https://www.uptodate.com/contents/treatment-of-ewing-sarcoma
Interval compressed chemotherapy for Ewing sarcoma - 2023-06-20 - https://www.uptodate.com/contents/image?imageKey=ONC%2F110260
[reconsidering doxorubicin in VDC/IE regimen for enhanced efficacy]
The VDC/IE regimen typically includes doxorubicin as a component, but it has been excluded since 2023-09-22. Given that the last 2D echocardiography on 2023-07-31 showed a LVEF of 70% with no apparent cardiotoxicity from doxorubicin, reintroducing doxorubicin could be considered if the patient tolerates it well. This would ensure the completeness of the regimen and potentially enhance its therapeutic effectiveness.
The patient’s condition of having a single kidney should not necessitate the omission of doxorubicin, as there is no requirement for dosage adjustment of doxorubicin for any level of kidney impairment.
The risk of cardiomyopathy associated with doxorubicin is related to the cumulative dose, with incidences ranging from 1% to 20% for cumulative doses between 300 mg/m2 and 500 mg/m2. According to our hospital records, the patient’s cumulative dose is still significantly below 300 mg/m2. Additionally, the chemotherapy preparation room is vigilant in monitoring cumulative doses, ensuring they do not exceed the safe lifetime limit, and will notify the relevant parties as the patient approaches this threshold.
Upon review of the PharmaCloud database and hospital HIS5 records, no medication reconciliation issues were identified.
[leukopenia and anemia]
The administration of the alternating chemotherapy regimen of VDC/IE and the nadir of WBC (< 1K/uL) and HGB (< 9g/dL) are as follows. It seems that the trough of WBC occurs around the 10th day after the administration of VDC, indicating a stronger correlation with VDC in terms of timing than with IE. As for HGB, the changes are not as dramatic as for WBC, but it can be confirmed that during the patient’s receipt of the VDC/IE regimen, the overall HGB level shows a decreasing trend. In addition, it’s worth mentioning that the patient received several transfusions and G-CSF during the treatment period, which are also factors influencing WBC and HGB.
2023-07-26 VDC regimen 2023-07-12 HGB 7.9 g/dL 2023-07-06 IE regimen 2023-06-28 WBC 0.16 x10^3/uL 2023-06-28 HGB 8.1 g/dL 2023-06-19 VDC regimen 2023-06-01 HGB 8.6 g/dL 2023-05-24 IE regimen 2023-04-27 WBC 0.33 x10^3/uL 2023-04-18 VDC regimen 2023-03-20 IE regimen 2023-03-17 HGB 8.7 g/dL 2023-03-01 WBC 0.35 x10^3/uL 2023-02-20 VDC regimen
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
TAC (Docetaxel, Doxorubicin and Cyclophosphamide) (breast) - https://www.swagcanceralliance.nhs.uk/wp-content/uploads/2020/10/TAC-1.pdf
A review of the patient’s medical records on 2023-12-20, revealed the development of dermatitis or hand-foot syndrome following chemotherapy treatment.
It is noteworthy that the patient is concurrently receiving 3 medications for her breast cancer - docetaxel, tamoxifen, and goserelin (Zoladex Depot - goserelin 10.8mg/syringe, SC on 2023-12-20, Q3M) - all of which have been associated with dermatological adverse reactions in the literature. The reported incidence of these reactions for each medication is as follows:
The development of subsequent skin symptoms may be difficult to definitively attribute to docetaxel, and further observation and follow-up is warranted.
As for the skin symptoms that have already occurred, the preliminary recommendation is to prescribe Sinphraderm and/or Mycomb to relieve them.
The TAC regimen, which includes docetaxel at 75 mg/m2 Q3W (initiated on 2023-09-27), followed 4 courses of doxorubicin and cyclophosphamide from 2023-05-03 to 2023-07-18. Docetaxel has been linked to dermatologic side effects such as alopecia (56% to 76%, with potential permanence), skin reactions (20% to 48%; severe reactions in 5%), and nail disorders (11% to 41%), as per UpToDate. To address these skin issues, a consultation with a dermatologist is recommended. The aim is to manage the patient’s comfort effectively while maintaining the current chemotherapy schedule and dosage.
Leukopenia episodes were noted on 2023-08-09, 2023-10-04, and 2023-11-15. Prompt administration of G-CSF was carried out in response to these occurrences. Currently, there are no indications of leukopenia.
[exam findings]
[MedRec]
[lab data]
2023-07-26 HBsAg Nonreactive
2023-07-26 HBsAg (Value) 0.24 S/CO
2023-07-26 Anti-HBs 39.06 mIU/mL
2023-07-26 Anti-HBc Nonreactive
2023-07-26 Anti-HBc-Value 0.31 S/CO
2023-07-26 Anti-HCV Nonreactive
2023-07-26 Anti-HCV Value 0.11 S/CO
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[leukopenia improved]
The administration of Granocyte (lenograstim) for 3 consecutive days, starting from 2023-12-03, has effectively improved the patient’s condition of leukopenia.
[leukopenia]
Two rounds of the gemcitabine and cisplatin regimen were given on 2023-11-21 and 2023-11-28. A leukopenia episode occurred on 2023-12-02, reaching a nadir WBC count of 0.33K/uL, and was treated with three consecutive days of Granocyte (lenograstim 250ug). Following this treatment, an initial increase in white blood cell count was observed.
The second session of treatment involved a reduced dose compared to the first, utilizing two-thirds of the gemcitabine dose and 80% of the cisplatin dose. The use of G-CSF did not present any issues.
[thrombocytopenia]
Thrombocytopenia has developed, and leukocyte-reduced platelet pheresis (LRP) is being administered (2023-12-04). Please continuously monitor the patient’s PLT levels.
[EGFR testing for SCC lung cancer]
Based on the available evidence, testing for EGFR mutations in patients with squamous cell carcinoma (SCC) of the lung is a topic of debate and ongoing research. While EGFR mutations are more commonly associated with lung adenocarcinoma, there is evidence to suggest that a small percentage of SCC patients also harbor EGFR mutations (Si et al., 2022; Nishimura et al., 2023). The presence of EGFR mutations in SCC lung cancer patients is important because these mutations can predict sensitivity to EGFR tyrosine kinase inhibitors (TKIs) (Shigematsu & Gazdar, 2006). However, the efficacy of EGFR-TKIs in SCC patients with sensitive EGFR mutations remains unclear (Chang et al., 2021). Additionally, the prevalence of EGFR mutations in SCC patients has been reported to be about 1-5% Si et al. (2022).
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
The patient recently obtained a 28-day supply of Norvasc (amlodipine) and Diovan (valsartan) on 2023-09-12, to manage his primary hypertension. These drugs have been added to the active medication list, and there were no reconciliation issues identified.
[diagnosis] - 2023-03-20 admission note
[past history] - 2023-03-20 admission note
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemoimmunotherapy]
dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mLIt appears that there is a suspicion of AKI in this patient due to the decline in renal function.
2023-07-16 Creatinine 4.13 mg/dL
2023-07-03 Creatinine 1.68 mg/dL
2023-07-16 eGFR 15.77
2023-07-03 eGFR 44.52
2023-07-16 BUN 71 mg/dL
2023-07-03 BUN 29 mg/dL
Based on the patient’s current renal status, the dosage of drugs in the active formulary has been reviewed and no adjustment is required.
According to the PharmaCloud database, our hospital has been the sole provider of all required medical services and medications for this patient for the past 3 months.
Our endocrinologist recently prescribed a refillable regimen of Tresiba Flex Touch (insulin degludec), Relinide (repaglinide), Trajenta (linagliptin), Aprovel (irbesartan), Tulip (atorvastatin), and Bokey (aspirin) on 2023-06-20. These drugs were added to the patient’s active medication list. As a result, no medication reconciliation issues were identified.
The most recent administration of CHOP was on 2023-06-16, and subsequent lab results indicate that leukopenia is still progressing. The use of G-CSF is covered by NHI when WBC < 1000/uL or ANC < 500/uL. Therefore, if the patient’s lab results meet these criteria, the use of G-CSF could be an appropriate management strategy. Please continue monitoring the patient’s WBC and ANC levels to make informed decisions about future treatment strategies.
Upon review of the PharmaCloud database, it is observed that the patient has exclusively sought medical care at our hospital for the past three months. No issues related to medication reconciliation have been identified.
The patient’s renal function has remained insufficient over the past month, with an eGFR of 26 on 2023-06-15. The dose of cyclophosphamide in the CHOP regimen has been adjusted in response to this renal insufficiency. Please continue to monitor the patient’s renal function and consider whether further dose adjustments are necessary.
In addition, the LFT also demonstrated an increase in ALT. According to Folyd’s 2006 recommendations, when a patient’s transaminases are 2 to 3 times the ULN, the dose of doxorubicin should be reduced to 75% of the standard dose. (The manufacturers’ guidelines suggest adjusting doses based on serum bilirubin levels. However, the most recent test results show that this patient’s bilirubin level is within the normal range.)
Based on the PharmaCloud database, the patient has only visited our hospital for medical needs in the past three months. After reviewing the database, no medication reconciliation issues were identified.
Lab results on 2023-05-11 indicate creatinine 3.26 mg/dL, eGFR 20.72, BUN 83 mg/dL, demonstrating the patient’s renal insufficiency. The rationale for dose adjustment in the CHOP regimen for patients with renal impairment is as follows:
The cyclophosphamide dose has been reduced to 75% since the last administration on 2023-03-24 as indicated without an issue.
The other medications listed in the active prescription should be used with caution, considering the patient’s renal insufficiency (ref: UpToDate):
Please continue to monitor regularly and consider dose adjustments as needed based on patient renal function.
[lab data]
2023-11-30 HBsAg Nonreactive
2023-11-30 HBsAg (Value) 0.35 S/CO
2023-11-30 Anti-HBc Reactive
2023-11-30 Anti-HBc-Value 6.35 S/CO
2023-11-30 Anti-HCV Nonreactive
2023-11-30 Anti-HCV Value 0.12 S/CO
[exam findings]
[consultation]
[thrombocytosis]
Thrombocytosis improves, cause remains unclear.
Elevated D-dimer levels, in conjunction with elevated fibrinogen, can further indicate the increasing risk of thrombosis and cardiovascular complications. The combination of elevated fibrinogen and D-dimer levels is considered a stronger risk factor for thrombosis than either one alone. Close monitoring is essential.
[diagnosis] - 2023-03-23 admission note
[past history]
[allergy]
[family history]
[lab data]
[exam findings]
[MedRec]
[consultation]
[MedRec]
[surgical operation]
[immunochemotherapy]
[note]
Acneiform eruption secondary to epidermal growth factor receptor (EGFR) and MEK inhibitors 2023-04-12 https://www.uptodate.com/contents/acneiform-eruption-secondary-to-epidermal-growth-factor-receptor-egfr-and-mek-inhibitors
CT scans from 2023-09-07 and 2023-06-08 both indicate mild regression of lymph nodes (LNs) and liver metastases, with a stable condition of bony metastases. This suggests that the Vectibix + FOLFOX regimen, initiated in Mar 2023, continues to be effective against the disease.
[potential folate-dependent anemia]
The patient has been on long-term iron supplementation, yet the MCV value is at the upper limit of the normal range (97.3 fL on 2023-10-30). While iron deficiency anemia typically presents with a low MCV, the observed decrease in HGB might be attributed to potential Vitamin B12 deficiency, folate deficiency, liver disease, or bone marrow dysfunction.
5-FU, a component of the FOLFOX regimen, disrupts DNA synthesis in cells. It acts by inhibiting the enzyme thymidylate synthase, which relies on folate for its activity. By inhibiting this enzyme, 5-FU can decrease the availability of active folate forms within cells. It’s plausible that the patient’s reduced HGB is related to folate deficiency.
After reviewing HIS5 records, there are no medication reconciliation issues. PharmaCloud is not accessible currently.
There are no medication reconciliation issues after review of PharmaCloud and HIS5 records.
According to the PharmaCloud database, our hospital has been the only medical institution providing care and prescriptions for this patient over the past three months. The Hemato-Oncology department is solely responsible for the patient’s recent medications. Hence, no medication reconciliation issues were detected.
Lab data on 2023-04-06 showed normal readings.
The patient’s anemia has improved with the use of Foliromin (ferrous sodium citrate) for the past 6 months. It is recommended to either discontinue or reduce the frequency of the medication from twice daily (BID) to once daily (QD) due to an expected decline in the marginal effect of iron supplementation, as the mean corpuscular volume (MCV) is approaches 100 fL.
In late Feb/early Mar 2023, the patient developed a localized skin eruption secondary to the epidermal growth factor receptor (EGFR) inhibitor panitumumab. He is currently adequately being treated with a topical regimen of tetracycline, metronidazole, silver sulfadiazine, and urea.
{DLBCL}
[exam findings]
[MedRec]
[chemotherapy]
A review of PharmaCloud and HIS5 records revealed no medication discrepancies. However, the patient’s serum LDH level has shown a concerning upward trend this month. Previously, it remained stable following the initiation of the R-COP regimen on 2023-09-22. This recent rise warrants considering an update of the medical images to better assess the effectiveness of the treatment on the underlying disease.
[hypoalbuminemia]
Hypoalbuminemia is emerging, and Plasbumin (human albumin) treatment was started on 2023-11-29.
Given the patient’s recent lab results indicating normal liver and kidney function, the likelihood of hypoalbuminemia resulting from albumin loss in urine due to nephrotic syndrome or reduced hepatic albumin synthesis is lower. Please verify if the patient is experiencing malnutrition and/or edema.
[leukopenia]
Episodes of leukopenia were noted approximately 1 to 2 weeks following the first cycle of R-COP on 2023-09-22 and the second cycle on 2023-10-11, specifically on 2023-10-04 and 2023-10-24. Granocyte (lenograstim) was appropriately administered for two periods of three consecutive days on these dates. Currently, there are no signs of leukopenia.
According to the National Health Insurance medication reimbursement regulations, short-acting G-CSF injections, such as filgrastim and lenograstim, are indicated for use after intravenous chemotherapy for hematologic malignancies. This patient should meet the criteria for such coverage.
[diagnosis] - 2023-05-01 admission note
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[proactive measures for leukopenia and renal function management]
After initiating the 5th cycle of R-COP/R-mCHOP on 2023-09-28, the patient experienced leukopenia in early Oct.
With a new session scheduled during this hospital stay, there’s a possibility of another leukopenia episode. Therefore, it may be advisable to have prophylactic G-CSF ready for use.
The patient has impaired renal function, but it is not severe enough to require dose adjustments for current medications. However, if the eGFR falls below 50 or creatinine exceeds 1.5, it’s important to consider adjusting the doses of Allegra (fexofenadine) and Lixiana (edoxaban).
[reconciliation]
[to adjust Dibose (acarbose) from BID to BIDCC]
Given the patient’s history of heart failure, doxorubicin may not be an appropriate component of the treatment regimen. Instead of R-CHOP, R-COP was chosen as the treatment regimen to avoid the potential cardiotoxic effects of doxorubicin.
On 2023-05-03, the progress note indicated that the patient had increased frequency of vomiting and difficulty with oral intake due to NG tube cough. Metoclopramide, a dopamine (D2) receptor antagonist, is currently prescribed. If symptoms persist, the addition of serotonin (5-HT3) receptor antagonists (such as ondansetron, granisetron, or palonosetron) and/or neurokinin-1 (NK1) receptor antagonists (such as aprepitant, fosaprepitant, rolapitant, or netupitant) may be considered. These medications work through different mechanisms to control nausea and vomiting and may provide additional relief for the patient.
Dibose (acarbose) should be taken with the first bite of each main meal or just before starting a meal for best results. Acarbose works by slowing down the digestion of carbohydrates in the intestines, helping to control blood sugar levels. Taking it at the beginning of a meal ensures its optimal effect on carbohydrate digestion. It is recommended to change the medication from current BID to BIDCC.
[exam finding]
[consultation]
2023-11-15 Infectious Disease
2023-09-25 Gastroenterology (not completed)
2023-09-25 Infectious Disease
2022-04-20 Radiation Oncology
2022-03-12 Radiation Oncology
2022-02-15 Radiation Oncology
2022-02-14 Gastroenterology
2022-01-25 General and Gastrointestinal Surgery
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
[Brosym dosage assessment for the patient with jaundice and poor renal function]
This patient has severe jaundice and poor kidney function, and is currently being treated with Brosym (cefoperazone, sulbactam) 4g IVD Q12H.
Sanford Guide:
The current dosage of Brosym is twice the recommended amount according to the Sanford Guide. Please consider reducing the dosage based on the clinical situation.
[biweekly gemcitabine-cisplatin and monthly pembrolizumab demonstrate sustained response]
The current treatment regimen, which includes biweekly administrations of gemcitabine and cisplatin, along with monthly pembrolizumab, initiated on 2023-08-15, seems to remain effective. This effectiveness is indicated by the decreasing trend in CA-199 levels and the stable readings of CEA.
2023-11-14 CA-199 (NM) 79.720 U/ml
2023-11-07 CA-199 (NM) 78.021 U/ml
2023-10-24 CA-199 (NM) 190.180 U/ml
2023-10-17 CA-199 (NM) 208.840 U/ml
2023-09-19 CA-199 (NM) 210.380 U/ml
2023-09-08 CA-199 (NM) 148.890 U/ml
2023-08-25 CA-199 (NM) 593.460 U/ml
2023-08-22 CA-199 (NM) 850.900 U/ml
2023-07-28 CA-199 (NM) 1253.210 U/ml
2023-05-26 CA-199 (NM) 23.184 U/ml
2023-03-10 CA-199 (NM) 11.934 U/ml
2022-11-18 CA-199 (NM) 11.891 U/ml
2022-11-07 CA-199 10.940 U/mL
2022-10-07 CA-199 (NM) 8.593 U/ml
2022-08-10 CA-199 (NM) 9.805 U/ml
2022-05-05 CA-199 (NM) 8.925 U/ml
2022-04-29 CA-199 (NM) 18.368 U/ml
2022-03-09 CA-199 (NM) 21.032 U/ml
2022-01-15 CA-199 103.380 U/mL
2023-11-14 CEA (NM) 7.340 ng/ml
2023-11-07 CEA (NM) 6.487 ng/ml
2023-10-24 CEA (NM) 7.002 ng/ml
2023-10-17 CEA (NM) 8.315 ng/ml
2023-09-19 CEA (NM) 5.347 ng/ml
2023-09-08 CEA (NM) 6.293 ng/ml
2023-08-25 CEA (NM) 7.052 ng/ml
2023-08-22 CEA (NM) 7.820 ng/ml
2023-07-28 CEA (NM) 6.275 ng/ml
2023-05-26 CEA (NM) 3.872 ng/ml
2023-03-10 CEA (NM) 4.042 ng/ml
2022-11-18 CEA (NM) 3.139 ng/ml
2022-11-07 CEA 3.090 ng/mL
2022-10-07 CEA (NM) 3.624 ng/ml
2022-08-10 CEA (NM) 2.325 ng/ml
2022-05-05 CEA (NM) 2.259 ng/ml
2022-04-29 CEA (NM) 3.142 ng/ml
2022-03-09 CEA (NM) 1.678 ng/ml
2022-01-15 CEA 3.380 ng/mL
[assessing the risk of edema in the context of increasing hypoalbuminemia]
The patient is exhibiting a trend of worsening hypoalbuminemia. Factors such as impaired liver function, suspected cholangitis, and infection could be contributing to this condition. It is advisable to check for the presence of edema, as indicated by the weight increase from 56.4 kg on 2023-11-08 to 60.8 kg on 2023-11-15.
[MedRec]
[chemotherapy]
2023-11-19 - melphalan 100mg/m2 160mg NS 500mL 1hr D1-2 (D-2,-1 conditioning regimen prior to APBSCT D0 2023-11-21)
2023-09-26 - bortezomib 1.3mg/m2 2.2mg SC (VTd)
2023-09-19 - bortezomib 1.3mg/m2 2.2mg SC (VTd)
2023-07-07 - cyclophosphamide 3000mg/m2 4800mg NS 500mL 2hr (for PBSC harvest)
2023-06-16 - bortezomib 1.3mg/m2 2.2mg SC (VTd)
2023-06-09 - bortezomib 1.3mg/m2 2.2mg SC (VTd)
2023-06-02 - bortezomib 1.3mg/m2 2.2mg SC (VTd)
2023-05-26 - bortezomib 1.3mg/m2 2.2mg SC (VTd)
2023-05-19 - bortezomib 1.3mg/m2 2.2mg SC (VTd)
2023-05-12 - bortezomib 1.3mg/m2 2.2mg SC (VTd)
2023-05-05 - bortezomib 1.3mg/m2 2.1mg SC (VTd)
2023-04-28 - bortezomib 1.3mg/m2 2.1mg SC (VTd)
2023-04-21 - bortezomib 1.3mg/m2 2.1mg SC (VTd)
2023-04-14 - bortezomib 1.3mg/m2 2.1mg SC (VTd)
2023-04-07 - bortezomib 1.3mg/m2 2.1mg SC (VTd)
2023-03-31 - bortezomib 1.3mg/m2 2.1mg SC (VTd)
2023-03-24 - bortezomib 1.3mg/m2 2.1mg SC (VTd)
2023-03-17 - bortezomib 1.3mg/m2 2.1mg SC (VTd)
2023-03-09 - bortezomib 1.3mg/m2 2.1mg SC (VTd)
Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma - 2023-11-29 - https://www.uptodate.com/contents/image?imageKey=ONC%2F101205
Cycle length: 28 days.
Regimen
[APBSCT day 8: minor WBC rise, no PLT improvement]
Today is Day 8 post-APBSCT, and there is a slight increase in the WBC level observed. However, the PLT remains low and has not shown any signs of rising.
2023-11-29 WBC 0.73 x10^3/uL D08
2023-11-27 WBC 0.03 x10^3/uL D06
2023-11-26 WBC 0.02 x10^3/uL D05 nadir
2023-11-25 WBC 0.53 x10^3/uL D04
2023-11-24 WBC 4.25 x10^3/uL D03
2023-11-23 WBC 11.14 x10^3/uL D02
2023-11-22 WBC 3.81 x10^3/uL D01
2023-11-20 WBC 5.23 x10^3/uL D-1
2023-11-29 PLT 18 *10^3/uL D08
2023-11-27 PLT 53 *10^3/uL D06
2023-11-26 PLT 78 *10^3/uL D05
2023-11-25 PLT 28 *10^3/uL D04
2023-11-24 PLT 51 *10^3/uL D03
2023-11-23 PLT 75 *10^3/uL D02
2023-11-22 PLT 98 *10^3/uL D01
2023-11-20 PLT 143 *10^3/uL D-1
Based on the lab results from 2023-11-29, the patient’s liver and kidney functions are normal, indicating no need for dosage adjustments due to liver or renal concerns.
[tube feeding]
Concor 5mg - For administration, employ the Simple Suspension Method (SSM). This involves dissolving the tablet in warm drinking water, leaving it for 5-10 minutes, and occasionally stirring or gently shaking the container until the tablet fully dissolves. Once dissolved, it can be administered through a feeding tube. This technique is particularly useful for dissolving tablets and capsules in warm water, making them suitable for suspension and feeding tube administration.
Harnalidge 0.4mg - Since Harnalidge (tamsulosin 0.4mg) is not appropriate for tube feeding, it is advised to transition to Urief (silodosin 8mg) as a suitable alternative to meet the patient’s requirements.
[minutes of interprofessional practice and family meeting]
Today, at 11:00 on 2023-11-16, an interprofessional practice and family meeting was convened by the attending physician, Dr. Gao, in the conference room of Ward 11A. The patient, along with his wife and only son, attended the meeting.
Dr. Gao provided the patient and his family with a comprehensive explanation about the current status of the disease, prognosis, the expected outcomes and risks associated with autologous PBSCT, and asked several questions to assess whether the family fully understood the situation.
Before the meeting, I visited the family and informed that the patient’s bilirubin levels were slightly elevated, but renal function was normal, and there was currently no need to adjust dosages due to liver or kidney function status.
As the patient’s hearing has been gradually declining, I suggested during the post-meeting casual conversation that, once the transplantation procedure is completed and the patient is in a stable condition, he should consider consulting an otolaryngologist to explore further corrective measures, such as getting a hearing aid.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[Akynzeo use for prolonged nausea control post-chemotherapy]
On 2023-11-21, the patient was administered cisplatin at 40mg/m2, with premedication including dexamethasone, diphenhydramine 30mg, palonosetron 250ug, and NS hydration.
Post-treatment, the patient experienced nausea and vomiting for an additional three days, leading to the prescription of metoclopramide.
For subsequent chemotherapy sessions, it may be beneficial to consider Akynzeo, available in this hospital. Akynzeo, containing netupitant, an NK-1 receptor antagonist with a 96-hour half-life, could provide prolonged anti-emetic effects.
[hypomagnesemia and hypokalemia]
Cisplatin is a common cause of hypomagnesemia and hypokalemia due to renal magnesium (Mg) and potassium (K) losses.
2023-11-27 K (Potassium) 3.1 mmol/L
2023-11-24 K (Potassium) 3.8 mmol/L
2023-11-23 K (Potassium) 4.9 mmol/L
2023-11-27 Mg (Magnesium) 1.8 mg/dL
2023-11-06 Mg (Magnesium) 1.9 mg/dL
Magnesium (MgO) and potassium (Const-K) supplements are currently in use. There is no problem with the supplementation.
[mild hyponatremia]
Based on the laboratory data, mild hyponatremia has been consistently observed for the past month and a half, and it may be considered to investigate the possible underlying causes.
[elevated BUN]
Cisplatin primarily injures the S3 segment of the proximal tubule. Urea undergoes a more complex process involving reabsorption and secretion in different parts of the tubules, while creatinine is not significantly reabsorbed after filtration. The elevated BUN may be a vague indication of cisplatin nephrotoxicity.
Every oral medication listed as currently active is suitable for administration via a feeding tube.
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[exam findings]
[MedRec]
[surgical operation]
[immunochemotherapy]
2023-11-21 - (Avastin + FOLFIRI) Xia He Xiong
2023-11-01 - (Avastin + FOLFIRI) Xia He Xiong
2023-10-13 - (Avastin + FOLFIRI) Xia He Xiong
2023-09-22 - (FOLFIRI) Xia He Xiong
2023-09-01 - (FOLFIRI) Xia He Xiong
2023-08-22 - (FOLFOX) Chen XinHong
2023-08-07 - (FOLFOX) Xiao GuangHong
2023-07-24 - (FOLFOX) Xiao GuangHong
2023-07-10 - (FOLFOX) Xiao GuangHong
2023-06-26 - (FOLFOX) Xiao GuangHong
2023-06-12 - (FOLFOX) Xiao GuangHong
2023-05-29 - (FOLFOX) Xiao GuangHong
[lab data]
2023-04-07 Anti-HBs 64.07 mIU/mL
2023-04-07 Anti-HBc Nonreactive
2023-04-07 Anti-HBc Value 0.08 S/CO
2023-04-07 Anti-HCV Nonreactive
2023-04-07 Anti-HCV Value 0.06 S/CO
2023-04-07 HBsAg Nonreactive
2023-04-07 HBsAg (Value) 0.47 S/CO
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[reduced chemotherapy dosage in this hospitalization]
The dosage of the paclitaxel-cisplatin regimen given during this hospital stay was decreased to 60% of the previous amount, taking into account the patient’s ability to tolerate the treatment.
While the CEA and CA125 markers are within normal limits, the rising CA199 levels may indicate underlying conditions that are yet to be identified and warrant further investigation.
The drugs prescribed by VGHTPE on 2023-10-16 are currently in use, no medication discrepancy is found.
The drugs rufinamide, lamotrigine, topiramate, lacosamide, perampanel, and clobazam refilled on 2023-09-08 to treat the patient’s “localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus” are currently in use with no discrepancy found.
No medication discrepancy has been found.
[reconciliation]
This patient recently refilled a 30-day prescription on 2023-07-24, provided by Taipei Veterans General Hospital, for rufinamide, lamotrigine, topiramate, lacosamide, perampanel, and clobazam to manage her “localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus.” However, these medications are not currently in use. Please verify if there is no longer a need for these drugs.
[leukopenia]
The organization of WBC level changes is as follows, where * represents WBC < 3K/uL, ** represents WBC < 2K/uL. Leukopenia, which occurred in late May and worsened in mid-June, is more likely the result of the cumulative effects of multiple CCRTs when considering the treatment timeline. After each dose of Granocyte (lenograstim 250ug) administered on 2023-06-29 and 2023-07-01, leukopenia is currently no longer present.
2023-07-13 WBC 5.96 x10^3/uL 2023-07-06 WBC 4.03 x10^3/uL
2023-06-29 WBC 1.64 x10^3/uL ** Granocyte (lenograstim 250ug) 06/29,
07/01 2023-06-15 WBC 1.59 x10^3/uL ** concurrent CDDP 06/08 2023-06-07
WBC 2.05 x10^3/uL * concurrent CDDP 06/01 2023-05-31 WBC 2.02 x10^3/uL
*
2023-05-24 WBC 2.22 x10^3/uL * concurrent CDDP 05/18, 05/25 2023-05-17
WBC 3.21 x10^3/uL concurrent CDDP 05/11 2023-05-10 WBC 3.47 x10^3/uL
concurrent CDDP 05/04 2023-05-02 WBC 5.00 x10^3/uL
2023-03-30 WBC 10.44 x10^3/uL
2023-03-28 WBC 3.01 x10^3/uL
2023-03-08 WBC 3.31 x10^3/uL
2021-07-12 WBC 3.97 x10^3/uL
[paclitaxel administered, leukopenia needs to be monitored in the coming weeks]
[lab data]
2023-08-04 Anti-HBc Reactive
2023-08-04 Anti-HBc-Value 7.10 S/CO
2023-08-04 Anti-HBs 205.76 mIU/mL
2023-08-04 HBsAg Nonreactive
2023-08-04 HBsAg (Value) 0.27 S/CO
2023-08-04 Anti-HCV Nonreactive
2023-08-04 Anti-HCV Value 0.10 S/CO
[exam findings]
[MedRec]
[chemotherapy]
[abnormal liver function test results point to possible liver damage]
Laboratory findings indicate elevated liver function test (LFT) values, suggesting possible liver damage.
The patient has been receiving Baraclude (entecavir) and BaoGan (silymarin), and is prescribed Nexium (esomeprazole 40mg), taken as 1# QOD, no medication problem identified.
[dosing adjustments in hepatic impairment: guidelines for AC(Lipo) components]
The AC(Lipo) regimen being administered to this patient includes pegylated liposomal doxorubicin and cyclophosphamide.
Medication not found to be mismatched.
No discrepancy in the medication is found.
The AST to ALT ratio has been greater than 1 since the earliest available data from 2023-08-03. Please exclude the possibility of alcohol abuse in this patient. In addition, the subsequent initiation of cyclophosphamide from 2023-08-28 may also lead to hepatotoxicity.
[leukopenia]
A single dose of docetaxel (35mg/m2) was administered on 2023-08-12 before an episode of leukopenia was observed on 2023-08-21. Following a single injection of Granocyte (lenograstim 250ug), no further episodes of leukopenia have been observed to date.
2023-08-28 WBC 15.29 x10^3/uL
2023-08-23 WBC 19.11 x10^3/uL
2023-08-21 WBC 1.84 x10^3/uL 2023-08-16 WBC 6.88 x10^3/uL
2023-08-14 WBC 12.40 x10^3/uL
2023-08-12 WBC 7.95 x10^3/uL
2023-08-10 WBC 10.92 x10^3/uL
2023-08-03 WBC 9.67 x10^3/uL
2023-06-19 WBC 11.37 x10^3/uL
2023-08-28 Neutrophil 82.5 %
2023-08-25 Neutrophil 77.4 %
2023-08-23 Neutrophil 55.7 %
2023-08-21 Neutrophil 7.6 % 2023-08-16 Neutrophil 77.2 %
2023-08-14 Neutrophil 94.2 %
2023-08-10 Neutrophil 68.9 %
2023-08-03 Neutrophil 74.5 %
2023-06-19 Neutrophil 76.0 %
[monitor cardiac function going forward]
While 2D transthoracic echocardiography on 2023-08-09 showed preserved right ventricular systolic function, ECG on 2023-08-23 showed T-wave abnormalities consistent with anterior ischemia and prolonged QT interval. Since anthracyclines such as doxorubicin may prolong the QT interval, it would be prudent to monitor the condition after administration of (liposomal) doxorubicin (on 2023-08-28).
2023-08-04 breast biopsy pathology IHC revealed: ER (-), PR (-), Her2/neu (3+), CK5/6 (-), p63 (+ for myoepithelium).
NHI coverage for pertuzumab is applicable under the following conditions: 1. Pertuzumab, in combination with trastuzumab and docetaxel, is used to treat patients with HER2-positive (IHC3+ or FISH+) metastatic breast cancer who have not previously received treatment with anti-HER2 therapy or chemotherapy for metastasis. 2. Prior approval is required for usage, and after approval, efficacy assessment data must be provided every 18 weeks for re-application. If the disease worsens, re-application should not be pursued. The maximum coverage duration for each patient is limited to 18 months.
If doxorubicin is intended for use, it is advisable to conduct a pre-treatment 2D transthoracic echocardiography to establish the baseline heart function.
[MedRec]
[consultation]
[MultiTeam]
[immunochemotherapy]
Enhertu (trastuzumab deruxtecan) dosing
Lab data
Although the suggested dosage of the medication is 5.4mg/m2, the dose actually given was only around 40% of this recommendation. This significant reduction in dosage may lead to less than optimal treatment outcomes. (Enhertu is currently not covered by the NHI).
Please monitor for and promptly investigate signs and symptoms including cough, dyspnea, fever, and other new or worsening respiratory symptoms. Permanently discontinue fam-trastuzumab deruxtecan in all patients with >= grade 2 ILD/pneumonitis. Advise the patient of the risk and the need to immediately report symptoms.
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
2023-06-26 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4120mg NS 500mL 46hr (Avastin + FOLFOXIRI; Q2W)
2023-05-18
2023-04-20
2023-03-21
2023-03-03 - (Avastin + FOLFOX; Q2W)
2023-02-01 - (Avastin + FOLFOX; Q2W)
2022-12-23 - (Avastin + FOLFOX; Q2W)
2022-12-02 - (Avastin + FOLFOX; Q2W)
2022-11-15 - (Avastin + FOLFOX; Q2W)
2022-10-20 - (Avastin + FOLFOX; Q2W)
2022-09-16 - (Avastin + FOLFOX; Q2W)
2022-08-18 - (Avastin + FOLFOX; Q2W)
2022-08-01 - (Avastin + FOLFOX; Q2W)
2022-07-08 - (Avastin + FOLFOX; Q2W)
2022-06-17 - (Avastin + FOLFOX; Q2W)
2022-04-26 - (Avastin + FOLFOX; Q2W)
2022-04-08 - (Avastin + FOLFOX; Q2W)
2022-03-08 - (Avastin + FOLFOX; Q2W)
2022-02-10 - (Avastin + FOLFOX; Q2W)
2022-01-07 - (Avastin + FOLFOX; Q2W)
2021-12-21 - (Erbitux + FOLFOX; Q2W)
2021-11-03 - (Erbitux + FOLFOX; Q2W)
2021-10-18 - (Avastin + FOLFIRI; Q2W)
2021-09-29 - (Avastin + FOLFIRI; Q2W)
2021-07-29 - (Avastin + FOLFIRI; Q2W)
2021-07-09 - (Avastin + FOLFIRI; Q2W)
2021-06-25 - (Avastin + FOLFIRI; Q2W)
2021-06-07 - (Avastin + FOLFIRI; Q2W)
2021-05-21 - (Avastin + FOLFIRI; Q2W)
FOLFOXIRI chemotherapy for metastatic colorectal cancer - 2023-11-23 - https://www.uptodate.com/contents/image?imageKey=ONC%2F70559
FOLFIRINOX chemotherapy for metastatic pancreatic cancer - 2023-11-23 - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571
Modified FOLFIRINOX chemotherapy for pancreatic cancer - 2023-11-23 - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546
[rising tumor markers and progressive disease]
This patient has a history of multiple lines of treatment for her cancer, including:
Both CEA and CA199 have been rising for the past two months, consistent with the progressive disease seen on the CT scan on 2023-09-27.
2023-11-21 CEA (NM) 382.930 ng/ml
2023-10-24 CEA (NM) 130.315 ng/ml
2023-09-26 CEA (NM) 95.670 ng/ml
2023-11-21 CA-199 (NM) 4220.750 U/ml
2023-10-24 CA-199 (NM) 2298.450 U/ml
2023-09-26 CA-199 (NM) 1177.830 U/ml
As the liver metastases are more severe, more intensive monitoring of liver function might be advisable.
[mixed acid-base disorder?]
Here’s a breakdown of the results of the venous blood gas (VBG - 2023-11-22) values:
The results suggest a mild metabolic alkalosis, as indicated by the slightly elevated pH and bicarbonate levels, along with a positive base excess.
Meanwhile, lactic acid was elevated (2023-11-22 2.5 mmol/L), this could indicate lactic acidosis, a condition where there is an accumulation of lactic acid in the body, often due to inadequate oxygen delivery to tissues (hypoxia), shock, or other metabolic issues.
In the context of the mild metabolic alkalosis suggested by the vein blood gas results, elevated lactic acid could point towards a mixed acid-base disorder. This is where more than one acid-base imbalance is occurring simultaneously.
O2 cannula 3L/min has been ordered and the updated SpO2 is 95% (2023-11-23).
[exam findings]
[MedRec]
[consultation]
2023-09-10 Urology
2023-06-08
2023-05-19
2023-05-18
2023-05-17
2023-04-21 Hemato-Oncology
2023-04-20 Obstetrics and Gynecology
[chemotherapy]
2023-11-22 - paclitaxel 175mg/m2 170mg NS 250mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr + [docetaxel 30mg/m2 30mg + cisplatin 30mg/m2 30mg + gentamicin 40mg + sodium bicarbonate 3800mg + NS 1000mL] IP 1hr (70%)
2023-10-19 - paclitaxel 175mg/m2 170mg NS 250mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + gentamicin 40mg + sodium bicarbonate 3800mg + NS 1000mL] IP 1hr (70%)
2023-09-11 - [liposome doxorubicin 30mg/m2 40mg D5W 250mL + carboplatin AUC 5 900mg NS 250mL] IP 90min
2023-08-21 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2023-07-31 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2023-07-06 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2023-06-08 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2023-05-18 - paclitaxel 175mg/m2 135mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
2023-04-25 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 375mg NS 250mL 2hr
No medication reconciliation issues were found after reviewing PharmaCloud and HIS5.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[brentuximab vedotin] (not posted)
Health Insurance Medication Coverage Regulations (2023-10-24 version)
[family meeting] (not posted)
On the morning of 2023-11-22, at 10:00 AM in the 11A ward meeting room, a family meeting for the patient was convened by the attending physician, Dr. Gao. Attendees included the patient, her father, mother, elder sister, younger brother, and husband.
During the meeting, Dr. Gao thoroughly explained the current status of the disease, prognosis, and the conditions for health insurance coverage of targeted medications. The meeting particularly focused on ensuring that the patient’s family support network has a correct understanding of the condition and can provide timely support to the patient. The patient was also encouraged to actively raise any questions or concerns she might have during the treatment process and seek assistance from the medical team.
In an informal conversation after the meeting, outside the patient’s room, I further explained to the patient and her family about the risks of “tumor lysis syndrome” and “infusion reaction,” as well as the key points to cooperate with during treatment. The patient seemed willing to comply with the treatment.
[lab data]
2023/03/17 Anti-HBc (NM) = Positive; 2023/03/17 HBsAg (NM) = Negative; 2023/03/17 HBsAg Value (NM) = 0.454; 2023/03/17 Anti-HBs (NM) = Positive; 2023/03/17 Anti-HCV (NM) = Negative;
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
After the surgical operation on 2023-08-07 (Pancreato-duodenectomy Whipple procedure with reconstruction, which included partial gastrectomy, pancreato-duodenal anastomosis, Billroth II, and Braun anastomosis), the tumor marker CA199 significantly decreased from four digits to two digits.
Lab data from 2023-11-20 indicates that, apart from slightly impaired renal function, liver function, electrolytes, and blood counts are largely within normal ranges.
No medication discrepancies identified.
[vancomycin TDM]
U-Vanco (vancomycin) has been administered at a dose of 1000mg Q12H IVD since 2023-11-18, with scheduled administration times at 09:00 and 21:00. The blood sample was drawn on 2023-11-20 at 02:25:37, following the administration at 20:19 on 2023-11-19, and before the next dose at 12:47 on 2023-11-20. If the aim is to measure the trough level, the ideal time for blood sampling should be within half an hour before the next dose. Please confirm if the timing of the blood draw was correct.
If after confirmation, the blood draw timing is deemed accurate (indicating a vancomycin concentration of 22 mg/L is reliable), then the current dosage of 1000mg Q12H should be reduced to 750mg Q12H.
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[Kidney function fluctuates downward]
Lab:
2023-11-17 eGFR 60.17 ml/min/1.73m^2
2023-11-06 eGFR 80.68 ml/min/1.73m^2
2023-11-17 BUN 44 mg/dL
2023-11-06 BUN 19 mg/dL
It is recommended that 50% of the usual total daily dose of metoclopramide be given if CrCl falls between 10 and 60 mL/minute.
[decline in renal function over the last month]
The patient’s renal function has deteriorated over the past 30 days.
2023-10-26 BUN 60 mg/dL
2023-10-11 BUN 48 mg/dL
2023-10-05 BUN 34 mg/dL
2023-09-25 BUN 19 mg/dL
2023-10-26 Creatinine 1.12 mg/dL
2023-10-11 Creatinine 0.99 mg/dL
2023-10-05 Creatinine 0.92 mg/dL
2023-09-25 Creatinine 0.85 mg/dL
Carboplatin is associated with decreased creatinine clearance (27%), increased blood urea nitrogen (14% to 22%)
Valsartan may be associated with increased serum creatinine and/or acute kidney injury. Increases in serum creatinine secondary to angiotensin receptor blockers usually stabilize within 20% to 30% from baseline and are expected; additional increases may indicate renal artery stenosis or volume depletion.
Adverse events reported post-marketing include interstitial nephritis with famotidine, acute interstitial nephritis with amlodipine, and acute kidney injury, Fanconi syndrome, proximal tubular nephropathy, and renal tubular necrosis with tenofovir alafenamide.
After reviewing the PharmaCloud and HIS5 records for this admission, no medication reconciliation issues were identified.
No medication reconciliation issues were found when this admission after reviewing PharmaCloud and HIS5.
[lab data]
2023-07-24 Anti-HCV Nonreactive
2023-07-24 Anti-HCV Value 0.25 S/CO
2023-07-24 Anti-HBc Reactive
2023-07-24 Anti-HBc-Value 6.92 S/CO
2023-07-24 Anti-HBs 7.37 mIU/mL
2023-07-24 HBsAg Nonreactive
2023-07-24 HBsAg (Value) 0.27 S/CO
[exam findings]
[MedRec]
[consultation]
This is a 50 y/o male patient with underlying alcoholism, gout, GERD. He was admitted this time under the impression of: UGI bleeding, cellulitis of foot, and colitis of ascending colon and cecum, the patient was admitted for further evaluation and management. We were consulted for the irritable mood and suspect visual hallucination at night.
According to the patient and his wife: A 50-year-old male, living with his wife and son, was a logistics driver for over 10 years and has no history of psychiatric treatment. He left his job a month ago, stating that he resigned due to disagreements with his supervisor. He began social drinking in high school, and over time, the amount and strength of alcohol consumed gradually increased. He now drinks 350ml bottles of sorghum liquor, 1-2 bottles daily. When not drinking, he experiences cravings and withdrawal symptoms, and when drunk, he talks nonsense and reports seeing strange things.
The patient and his family indicate that about three weeks ago, after leaving his job, he resolved to stop drinking. He claims that he has not touched alcohol since that day (though his account is somewhat inconsistent). He has been staying at home feeling gloomy, depressed, and irritable, but denies having suicidal thoughts. His wife notes that he was mentally clear during this period but started feeling general weakness before admission to the hospital. After admission, he exhibited irritability, restlessness, incoherent speech, and possible visual hallucinations.
Upon visit, he showed mild muddy spirit, limited orientation to time, people and place, rather stable mood. Coherant but sometimes irrelevant speech. Currently denied suicide ideation, denied hallucination. Poor memory function for years. Confabulation(+/-), nystagmus(+), unsteady gait, withdrawal symptom(+): tremor, palpitation.
[chemotherapy]
[hyperkalemia episodes]
Episodes of hyperkalemia have occurred several times in the past 5 months. During this period, the highest recorded serum creatinine level was 1.8mg/dL, and the eGFR consistently remained above 40 mL/min/1.73m^2, suggesting that the kidneys should still have the capacity to excrete excess potassium.
Upon reviewing the patient’s recent medication history, it was found that olmesartan, a component of Sevikar, could be a potential cause of hyperkalemia, especially considering the patient’s risk factors such as renal dysfunction, diabetes mellitus, concurrent use of potassium-sparing diuretics, potassium supplements, and/or potassium-containing salts. Sevikar has already been discontinued. Additionally, propranolol, which is currently being used, has been sporadically reported in post-marketing studies to be associated with hyperkalemia, although it is considered a less likely cause.
Could hypoaldosteronism be a potential cause in this case?
[reconciliation]
On 2023-10-18, this patient just refilled his repeat prescription for a 28-day supply of MgO, lansoprazole, sennoside, Kentamin, sodium ferrous citrate, propranolol, febuxostat, quetiapine fumarate, lorazepam. No discrepancies have been found with these medications currently in use.
[alcohol abstinence]
Abstaining from alcohol is the foundation of managing alcohol-associated cirrhosis. This abstinence has been linked to improvements in fibrosis, as well as lower hepatic venous pressure gradients.
Lab tests (2023-11-07) revealed normal AST, ALT, and total bilirubin levels. If the cirrhosis worsens and becomes decompensated, Baraclude (entecavir 1mg) may be a viable treatment option.
[reconciliation]
Recent MCV and MCH levels have consistently been on the upper end of their normal range, suggesting that iron deficiency anemia is less probable. The ongoing use of the iron supplement Foliromin (ferrous sodium citrate) may be reduced.
2023-08-21 MCV 92.3 fL
2023-07-24 MCV 93.0 fL
2023-07-14 MCV 92.6 fL
2023-06-10 MCV 92.3 fL
2023-08-21 MCH 31.0 pg
2023-07-24 MCH 30.6 pg
2023-07-14 MCH 30.2 pg
2023-06-10 MCH 30.6 pg
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[elevated LDH: a sign of underlying tissue and/or liver damage?]
An increasing trend in LDH levels might suggest potential tissue or liver damage, warranting further investigation.
As per the available records, the patient’s general and gastroenterology surgeon issued a prescription on 2023-06-20, following the subtotal gastrectomy. The prescribed medications include B-Red (hydroxocobalamin), Mopride (mosapride citrate), Foliromin (ferrous sodium citrate), and Ulstop (famotidine). These medications were appropriately incorporated into the active medication list, and there were no identified reconciliation problems.
As per the records, our general and gastroenterological surgery department prescribed a 28-day course of B-Red (hydroxocobalamin), Mopride (mosapride citrate), Foliromin (ferrous sodium citrate), and Ulstop (famotidine) to this patient on 2023-06-20 due to his post subtotal gastrectomy status. These drugs have been correctly incorporated into the active medication list, and no reconciliation issues were identified.
[exam findings]
[lab data]
[exam findings] (not completed)
[MedRec]
[chemotherapy]
[lab data]
2023-05-05 Anti-HBc Reactive
2023-05-05 Anti-HBc-Value 6.66 S/CO
2023-05-05 Anti-HBs 414.12 mIU/mL
2023-05-05 Anti-HCV Nonreactive
2023-05-05 Anti-HCV Value 0.08 S/CO
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
There were no issues found during medication reconciliation, and based on the patient’s latest lab results indicating normal renal and liver function, no dose adjustments are required.
[MedRec]
[reconciliation]
On 2023-10-18, the patient attended JingMei Hospital for treatment of polyneuropathy and received a 28-day prescription for mecobalamin, chlorzoxazone, brotizolam, and trazodone. These medications have not been recorded in the current medication list. Please verify if this constitutes a discrepancy.
[MedRec]
[surgical operation]
[chemotherapy]
2023-11-09 A-FOLFIRI He JingLiang
2023-10-19 A-FOLFIRI He JingLiang
2023-09-22 A-FOLFIRI He JingLiang
2023-09-01 A-FOLFIRI He JingLiang
2023-08-07 A-FOLFIRI He JingLiang
2023-07-24 A-FOLFIRI He JingLiang
2023-07-06 A-FOLFIRI He JingLiang
2023-06-15 A-FOLFIRI He JingLiang
2023-05-19 A-FOLFIRI Wan XiangLin
2023-05-05 A-FOLFIRI Wan XiangLin
2023-04-07 A-FOLFIRI Wan XiangLin
2023-03-20 A-FOLFIRI Wan XiangLin
2023-03-03 FOLFIRI Wan XiangLin
2023-02-14 FOLFIRI Zhang ShouYi
2022-12-27 FOLFIRI Zhang ShouYi
2021-10-28 XELOX Xiao GuangHong
2021-10-07 XELOX Xiao GuangHong
2021-09-16 XELOX Xiao GuangHong
2021-08-26 XELOX Xiao GuangHong
2021-08-05 XELOX Xiao GuangHong
2021-07-15 XELOX Xiao GuangHong
2021-06-24 XELOX Xiao GuangHong
2021-06-03 XELOX Xiao GuangHong
Medication
{S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis on 2019-09-11 s/p post-Op adjuvant chemotherapy FOLFOX finishing in 2020-04 with periotneal seeding s/p laparoscope rt diaphram tumor excision 2021-06-09}
[past history]
Left thyrioid goiter for 3-4 years with follow up at Taipei City Hospital FuYou Branch
Gastric polyp, body s/p biopsy (biopsy: Hyperplastic polyp) in 2019/08
past operation
double cancer
[lab data]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
[Lonsurf combination therapy for mCRC: dosage considerations in patients with low BSA]
Both tumor markers CEA and CA199 trend upward in 2023.
2023-10-17 CEA 79.30 ng/mL
2023-09-05 CEA 34.28 ng/mL
2023-07-18 CEA 20.55 ng/mL
2023-05-30 CEA 12.06 ng/mL
2023-05-05 CEA 5.88 ng/mL
2023-04-03 CEA 4.42 ng/mL
2023-03-08 CEA 4.25 ng/mL
2023-01-31 CEA 3.12 ng/mL
2023-01-06 CEA 2.70 ng/mL
2023-10-17 CA199 389.11 U/mL
2023-09-05 CA199 69.02 U/mL
2023-07-18 CA199 71.84 U/mL
2023-05-30 CA199 60.36 U/mL
2023-05-05 CA199 56.00 U/mL
2023-04-03 CA199 82.57 U/mL
2023-03-08 CA199 85.56 U/mL
2023-01-31 CA199 83.54 U/mL
2023-01-06 CA199 69.10 U/mL
On 2023-10-17, at the patient’s Hemato-Oncology outpatient department visit, it was recorded that the patient and her family have opted for further treatment with TAS-102 (Lonsurf) along with bevacizumab, which they will be self-financing.
Lonsurf (two dosage combinations: trifluridine 15mg + tipiracil 7.065mg; trifluridine 20mg + tipiracil 9.42mg) is a temporary purchase item in our hospital currently.
Lonsurf combination therapy for patients with metastatic colorectal cancer: Oral 35 mg/m2/dose (based on the trifluridine component) twice daily on days 1 to 5 and days 8 to 12 of a 28-day cycle (in combination with bevacizumab; maximum per dose: trifluridine 80 mg); continue until disease progression or unacceptable toxicity.
The patient has a relatively low BSA. 2023-10-09 BH 150cm, BW 40.8kg -> BMI 18.1kg/m2, BSA 1.30m2.
Recommended trifluridine/tipiracil metastatic colorectal cancer dosagea according to the patient’s BSA will be 45mg (based on the trifluridine component) BID, i.e., [trifluridine 15mg + tipiracil 7.065mg] 3# BID.
[loss of appetite]
visiting the patient (with her daughter accompanied) at around 16:20 on 2021-08-13.
S:
O:
A:
Suggestion
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
2023-11-09 - bevacizumab 7.5mg/m2 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Avastin + paclitaxel + carboplatin; Q3W)
2023-10-09 - paclitaxel 150mg/m2 270mg NS 250mL 6hr + carboplatin AUC 5 700mg NS 250mL 2hr + [docetaxel 30mg/m2 55mg + cisplatin 30mg/m2 55mg + gentamicin 40mg + NaHCO3 2800mg + NS 800mL] IP 1hr
2023-09-18 - paclitaxel 150mg/m2 270mg NS 250mL 6hr + carboplatin AUC 4 500mg NS 250mL 2hr + [docetaxel 30mg/m2 54mg + cisplatin 30mg/m2 54mg + gentamicin 40mg + NaHCO3 2800mg + NS 800mL] IP 1hr
2023-08-28 - paclitaxel 150mg/m2 270mg NS 250mL 6hr + carboplatin AUC 4 500mg NS 250mL 2hr (paclitaxel + carboplatin; Q3W)
2023-08-24 - bevacizumab 5mg/kg 600mg NS 500mL 90min (Avastin)
2023-08-07 - [liposome doxorubicin 30mg/m2 60mg D5W 250mL + carboplatin AUC 5 750mg NS 250mL] IP 90min (HIPEC)
2023-07-04 - paclitaxel 175mg/m2 300mg NS 250mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr
2023-06-12 - paclitaxel 175mg/m2 300mg NS 250mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr
2023-05-22 - paclitaxel 175mg/m2 300mg NS 250mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr
[sustained response to neoadjuvant and adjuvant therapy]
The patient underwent 3 cycles of paclitaxel and carboplatin neoadjuvant chemotherapy between 2023-05-22 and 2023-07-04. On 2023-08-07, she underwent surgery for ovarian cancer debulking, removal of intraabdominal malignant tumors, omentectomy, adhesiolysis, and HIPEC. Since then, she has received several cycles of paclitaxel and carboplatin adjuvant therapy. Both tumor markers, CA125 and CEA, continue to decrease, suggesting that the treatment is still effective.
2023-10-20 CA-125 (NM) 24.145 U/ml
2023-10-03 CA-125 (NM) 30.618 U/ml
2023-09-11 CA-125 (NM) 53.641 U/ml
2023-08-29 CA-125 (NM) 58.890 U/ml
2023-07-25 CA-125 (NM) 105.698 U/ml
2023-07-07 CA-125 (NM) 945.500 U/ml
2023-06-27 CA-125 (NM) 1417.280 U/ml
2023-06-06 CA-125 (NM) 1071.020 U/ml
2023-05-13 CA-125 782.100 U/mL
2023-10-20 CEA (NM) 6.433 ng/ml
2023-10-03 CEA (NM) 7.930 ng/ml
2023-09-11 CEA (NM) 9.771 ng/ml
2023-08-29 CEA (NM) 8.772 ng/ml
2023-07-25 CEA (NM) 74.188 ng/ml
2023-07-07 CEA (NM) 113.983 ng/ml
2023-06-27 CEA (NM) 95.131 ng/ml
2023-06-06 CEA (NM) 22.970 ng/ml
2023-04-22 CEA 17.240 ng/mL
Based on the PharmaCloud database, our hospital has been the exclusive healthcare provider for this patient in the past three months. Additionally, according to HIS5 records, our cardiologist issued a repeat prescription on 2023-08-18, which included Xarelto (rivaroxaban), Ulstop (famotidine), and Concor (bisoprolol). All of these medications have been added to the active medication list, and there were no issues identified during the reconciliation process.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[monitoring CEA levels post-Hartmann surgery: signs of emerging resistance to FOLFIRI regimen]
The Hartmann procedure was performed on 2022-12-24, after which the tumor marker CEA significantly decreased to within normal limits and remained so until August 2023. Recently, there has been an increase in the CEA levels, which could indicate the potential emergence of resistance to the current treatment regimen FOLFIRI which has been initiated since 2023-02-16.
[small bowel obstruction]
On 2023-11-08, a CT scan revealed a small bowel obstruction (SBO) in the patient, with a prior episode of postoperative ileus evidenced by KUB imaging in January 2023.
Patients with SBO may experience significant fluid loss, metabolic acidosis or alkalosis, and electrolyte imbalances. This is particularly true for patients with prolific vomiting from a proximal SBO, those with symptoms lasting several days before presentation, or those with an obstruction that results in large-volume fluid sequestration within the bowel. The patient is currently on an intravenous regimen of normal saline 500mL twice daily and Taita No.5 solution 500mL every 12 hours, which is considered an appropriate treatment.
In cases of SBO with significant distension, nausea, and/or vomiting, nasogastric tube decompression may be considered. Patients with these symptoms likely have a complete or high-grade obstruction; decompression can improve comfort and minimize the worsening of distension due to swallowed air.
Antibiotics are indicated if there is a suspicion of bowel compromise, such as ischemia, necrosis, or perforation.
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[leukopenia, thrombocytopenia]
The weekly administrations of cisplatin on 2023-10-04, 2023-10-11, 2023-10-18, and 2023-10-25 are an integral part of the current concurrent chemoradiotherapy (CCRT) treatment. However, the patient’s WBC and PLT recovery appears to be insufficient, resulting in a continued decline in WBC and PLT counts. Consequently, chemotherapy has been temporarily suspended, and a regimen of G-CSF (filgrastim) 300mg SC QD was commenced on 2023-11-07. A platelet transfusion will also be performed today (2023-11-08).
2023-11-08 WBC 1.73 x10^3/uL **
2023-11-07 WBC 1.30 x10^3/uL **
2023-10-31 WBC 2.33 x10^3/uL *
2023-10-24 WBC 3.36 x10^3/uL
2023-10-17 WBC 4.63 x10^3/uL
2023-10-09 WBC 6.55 x10^3/uL
2023-10-03 WBC 6.27 x10^3/uL
2023-11-08 PLT 34 10^3/uL **
2023-11-07 PLT 30 10^3/uL **
2023-10-31 PLT 67 *10^3/uL **
2023-10-24 PLT 142 10^3/uL
2023-10-17 PLT 250 *10^3/uL
2023-10-09 PLT 299 *10^3/uL
2023-10-03 PLT 314 *10^3/uL
There is a slight increase in WBC and PLT, according to the preliminary observation today.
[acute otitis media]
Ref: Otitis Media, Acute, Empiric Therapy - https://webedition.sanfordguide.com/en/sanford-guide-online/disease-clinical-condition/otitis-media
In treating adult acute otitis media (AOM) without prior antibiotic exposure in the preceding month, the following therapeutic options can be considered:
For patients who have received antibiotics in the previous month, alternative treatments include:
The standard duration for treatment is 10 days, although it is important to note that the course for Levofloxacin is 5 days.
At present, the patient is being treated with Soonmelt (amoxicillin 500mg, clavulanic acid 100mg) 1200mg IVD Q8H, which is considered an appropriate treatment.
[alarming trend: kidney function deteriorates over the past two months]
Kidney function has shown a worsening trend in the last two months.
The current dose of cisplatin used in concurrent chemoradiotherapy (CCRT) is lower than that used in the earlier TPF regimen, and adequate hydration has been provided during administration. To further protect renal function after recovery from the recent leukopenia and thrombocytopenia event, and if CCRT treatment is to continue, additional renal protective options include:
Ethyol (amifostine): A cytoprotective agent that can be administered prior to cisplatin to guard against nephrotoxicity by selectively shielding normal tissues from the harmful effects of chemotherapy. However, this medication is currently not available at our institution.
Magnesium Supplementation: To counteract the magnesium wasting caused by cisplatin, which can lead to nephrotoxicity, magnesium supplements may be administered to prevent hypomagnesemia.
Potassium Supplementation: Administered to replenish potassium lost during cisplatin treatment, as cisplatin can cause potassium to be excreted in the urine, potentially leading to hypokalemia.
N-acetylcysteine (NAC): An antioxidant considered to protect the kidneys from damage induced by cisplatin through the reduction of oxidative stress.
Diuretics: Agents like mannitol may be used alongside hydration to induce diuresis, which can help prevent the accumulation of cisplatin in the kidneys.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
Lab results remained largely unremarkable on 2023-12-21. Medication reconciliation confirmed no discrepancies.
Notably, the addition of bevacizumab to the paclitaxel + carboplatin regimen since 2023-11-07 has been associated with a sustained decline in CA-125 levels. Additionally, no adverse events related to bevacizumab, such as hypertension, gastrointestinal perforation, bleeding, or thromboembolic events, have been reported to date.
Upon review of the PharmaCloud database, the patient’s medication records are consistent with no discrepancies.
Following the cytoreductive surgery performed on 2023-08-29 and 2 subsequent cycles of the paclitaxel and carboplatin regimen administered on 2023-09-25 and 2023-10-16, there was a significant reduction in the tumor marker CA-125.
Avastin (bevacizumab) has been added to the treatment protocol beginning with the 3rd cycle. The patient should be closely monitored for signs of hypertension, gastrointestinal perforation, bleeding or thromboembolic events.
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
The patient’s repeat prescription from WanFang Hospital, which includes clopidogrel, nicorandil, indapamide, nifedipine, rosuvastatin, and benzbromarone, was last filled on 2023-10-17. However, not all of these medications are listed as currently active. Verification is required to determine if the medications not in use have been intentionally discontinued.
[exam findings] (not completed)
[MedRec]
[surgical operation]
[immunochemotherapy]
[leukopenia; G-CSF administration is usually begun 24 to 72 hours after cessation of chemotherapy]
Continuing from the previous pharmacist note replied on 2023-10-30.
New episodes of leukopenia were observed in late Oct and early Nov. Granocyte (lenograstim) was administered on 2023-11-03, just prior to paclitaxel chemotherapy.
Timing of G-CSF - When used for primary and secondary prophylaxis, therapy is usually begun 24 to 72 hours after cessation of chemotherapy. (https://www.uptodate.com/contents/use-of-granulocyte-colony-stimulating-factors-in-adult-patients-with-chemotherapy-induced-neutropenia-and-conditions-other-than-acute-leukemia-myelodysplastic-syndrome-and-hematopoietic-cell-transplantation)
[leukopenia]
Several episodes of leukopenia have been observed since the start of immunochemotherapy on 2023-04-15. The most recent episode occurred on 2023-10-27 with WBC at 1.86K, neutrophil and band at 58.9%, and ANC at 1095. This coincided with the administration of adjuvant paclitaxel. Paclitaxel has a known association with leukopenia (90%; grade 4: 17%). It’s generally not recommended for patients with solid tumors who have a baseline neutrophil count below 1500/uL. If there’s a high risk of infection, the use of G-CSF is recommended.
[exam findings]
[MedRec]
[chemmotherapy]
Gemcitabine and cisplatin for locally advanced or metastatic biliary tract and pancreatic cancer - 2023-11-06 - https://www.uptodate.com/contents/image?imageKey=ONC%2F89633
Cycle length: 21 days.
Duration of therapy: Maximum of 8 cycles.
Regimen
[reconciliation]
The patient recently renewed her prescriptions for lorazepam and alprazolam on 2023-10-31 at a community pharmacy. Alprazolam is listed as currently in use, but lorazepam is not included in the active medication list. It might be advisable to ascertain if lorazepam is no longer required.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[tube feeding]
All of the oral medications on the active medication list can be administered through a feeding tube.
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemoimmunotherapy]
[hyperglycemia]
During this hospital stay, the patient’s blood glucose levels have consistently been elevated (216 -> 376 -> 294 mg/dL).
It is advisable to introduce acarbose 50mg PO TIDCC, with the patient instructed to take each dose at the beginning of every main meal.
On 2023-08-08, our endocrinologist provided a repeat prescription for Glimet (glimepiride, metformin) and Trajenta (linagliptin), which the patient is currently taking without discrepancies. However, the patient’s blood glucose levels have been consistently high, >= 285 mg/dL for these 2 days. As a recommended addition to his treatment plan, the prescription of Dibose (acarbose 100mg) is advised to be taken as 0.5# TID, with the first bite of each main meal.
Glimet (glimepiride, metformin) and Trajenta (linagliptin) were refilled on 2023-07-05 as a repeat prescription prescribed by our endocrinologist on 2023-05-16. Both medications have been added to the active medication list without any identified issues.
At 20:14 on 2023-07-27, there was a spike in blood glucose to 269 mg/dL. If this elevation persists, it may require re-evaluation and possible modification of the antidiabetic treatment plan.
There appears to be an upward trend in liver enzyme levels. Given this situation, the addition of BaoGan (silymarin) could be considered as an optional measure if there are no other specific concerns.
2023-07-25 S-GPT/ALT 73 U/L
2023-07-13 S-GPT/ALT 50 U/L
2023-07-13 S-GPT/ALT 51 U/L
2023-06-28 S-GPT/ALT 31 U/L
2023-06-15 S-GPT/ALT 28 U/L
2023-07-25 S-GOT/AST 49 U/L
2023-07-13 S-GOT/AST 34 U/L
2023-07-13 S-GOT/AST 33 U/L
2023-06-28 S-GOT/AST 26 U/L
2023-06-15 S-GOT/AST 27 U/L
According to the PharmaCloud database, our hospital has been the sole provider of the patient’s medical services for the past three months. On 2023-06-24, our Thoracic Department issued a 7-day prescription for Curam (amoxicillin, clavulanic acid), Actein (acetylcysteine), Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), and MgO. Due to changes in the patient’s condition, Curam and MgO are not currently on the active formulary, indicating that these medications may no longer be needed. Therefore, no evidence of medication reconciliation discrepancies was identified.
[lab data]
2023-09-20 Anti-HBc Reactive
2023-09-20 Anti-HBc Value 3.40 S/CO
2023-09-20 Anti-HBs 191.16 mIU/mL
2023-09-20 Anti-HCV Nonreactive
2023-09-20 Anti-HCV Value 0.12 S/CO
2023-09-20 HBsAg Nonreactive
2023-09-20 HBsAg (Value) 0.32 S/CO
[exam findings]
[MedRec]
[chemotherapy]
Induction Chemotherapy With Mitomycin, Epirubicin, Cisplatin, Fluorouracil, and Leucovorin Followed by Radiotherapy in the Treatment of Locoregionally Advanced Nasopharyngeal Carcinoma - https://sci-hub.se/10.1200/JCO.2001.19.23.4305
Access to the patient’s PharmaCloud records is currently unavailable.
Following the initial cycle of the MEPFL regimen, leukopenia was noted for several days. Prompt intervention with G-CSF effectively alleviated this episode.
The second cycle of the MEPFL regimen incorporated a “scaled-down” version of the “MEP” components (mitomycin 6mg/m2, epirubicin 50mg/m2, cisplatin 50mg/m2) compared to the first cycle (mitomycin 8 mg/m2, epirubicin 60 mg/m2, cisplatin 60 mg/m2), as per the original trial (https://doi.org/10.1200/jco.2001.19.23.4305). This modification aimed to mitigate the recurrence of such episodes.
There is no discrepancy found in the medication.
[MedRec]
[surgical operation]
[immunochemotherapy]
[grade 3 diarrhea]
Based on the bowel movement records from the HIS5’s TPR panel, the patient has not had any instances of bowel movements reaching seven times in a day during her last three hospital stays.
It has been documented that the occurrence of diarrhea is linked with trastuzumab (7% to 25%), pertuzumab (46% to 67%), and neratinib (diarrhea at 95%; severe diarrhea: 2%). Given that the use of trastuzumab and pertuzumab started in Sep 2022 and has been continuous since then, and neratinib was only introduced in mid-Sep 2023, and its likelihood of causing diarrhea is higher than the former two, it is plausible that the recent episode of grade 3 diarrhea is more likely attributed to neratinib.
The prescription of Smecta and loperamide is an appropriate measure.
The patients should be reminded to maintain a fluid intake of approximately 2 L/day to prevent dehydration. Once the diarrhea improves to grade 1 or returns to baseline, it is recommended to initiate loperamide at 4 mg with each subsequent dose of neratinib.
{Prostate cancer, pT3bN1cM0, s/p RARP on 2015-06-30, s/p adjuvant radiotherapy on 2015-09-25 and hormone therapy with refractory, progression of metastatic paraaortic lymph nodes and bone metastases, T0N0M1a, stage IV}
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
2023-01-04 lab data were generally normal, except for a slight decrease in WBC and HGB levels. The vital signs of the patient are stable during this hospitalization.
All underlying conditions, including HBV, hypothyroidism, and insomnia, are managed with appropriate medication.
assessment
suggestion
assessment
suggestion
[lab data]
2023-09-20 HBsAg Nonreactive
2023-09-20 HBsAg (Value) 0.36 S/CO
2023-09-20 Anti-HBc Reactive
2023-09-20 Anti-HBc-Value 5.86 S/CO
2023-09-20 Anti-HCV Nonreactive
2023-09-20 Anti-HCV Value 0.06 S/CO
[exam findings]
[consultation]
[chemotherapy]
A potassium supplement was prescribed due to hypokalemia (K level of 3.3 mmol/L on 2023-10-30). Currently, no medication discrepancies have been identified.
[tube feeding]
All oral medications on the active drug list can be tube-fed.
[trend towards anemia]
The lab data indicates a trend towards anemia. HGB levels during CCRT have been consistently decreasing. Please continue to monitor the levels and determine if a blood transfusion is necessary.
All of the oral medications on the list of active medications can be administered by tube feeding.
2023-09-20 Anti-HBc Reactive indicates tenofovir or entecavir as preventive therapy for potential hepatitis B virus reactivation prior to planned CCRT.
[lab data]
[exam findings]
[MedRec]
[immunochemotherapy]
According to the PharmaCloud database, the patient’s medical care has exclusively been provided by our hospital in the recent 3 months. Consequently, no discrepancies in medication reconciliation have been detected.
Based on the PharmaCloud database, the patient has only received medical services from our hospital for the past three months. As a result, no medication reconciliation issues have been identified.
[lab data]
2023-09-20 HBsAg (NM) Negative
2023-09-20 HBsAg Value (NM) 0.422
2023-09-20 Anti-HBc (NM) Positive
2023-09-20 Anti-HBc Value (NM) 0.01
2023-09-20 Anti-HCV (NM) Negative
2023-09-20 Anti-HCV Value (NM) 0.042
2023-09-20 Anti-HBs (NM) Positive
2023-09-20 Anti-HBs value (NM) 46.4 mIU/mL
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
PharmaCloud data indicates that the patient has only been to our hospital within the last three months. Our urologist prescribed a refill of Harnalidge (tamsulosin) on 2023-09-26, and the medication is currently being used without any issues.
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[patient’s weight is too light]
A dosage of 1# QD could be considered appropriate for this patient with a less severe condition, given his body weight of 37 kg. This dosage is approximately equivalent to 1.5# QD for a patient weighing 57 kg.
[reconciliation]
The patient obtained a 28-day refill of the repeat prescription for Dilantin Kapseals (phenytoin) for his “absence epileptic syndrome, not intractable, with status epilepticus” from Taipei City Hospital on 2023-08-04. However, the patient is currently not taking phenytoin (according to the active medication list). It is recommended to assess whether the patient’s neurological symptoms persist and to determine the continued necessity of the drug.
[lab data]
2023-09-14 Anti-HBc Reactive
2023-09-14 Anti-HBc-Value 1.30 S/CO
2023-09-14 Anti-HBs 127.72 mIU/mL
[MedRec]
[surgical operation]
[chemotherapy]
[exam findings]
[MedRec]
[surgical operation]
[immunochemotherapy]
Upon reviewing both PharmaCloud and HIS5 records, no medication discrepancies were detected. However, PharmaCloud indicates that the patient visited MinSheng Hospital and received a diagnosis of an unspecified UTI on 2023-10-18. It may be prudent to verify that the UTI has been resolved.
Dipeptiven ref: https://www.fresenius-kabi.com/nz/documents/Dipeptiven_Datasheet.pdf
Based on the information in the PharmaCloud database, our hospital has been the exclusive provider of all necessary medical services and medications for this patient for the past three months. All current medications have been prescribed by our hemato-oncology department. Therefore, no medication reconciliation issues have been identified.
The recent lab results indicate a decreasing trend in the patient’s CEA level, potentially suggesting that the current regimen of FOLFIRI plus Avastin is effective. On the other hand, the gradually increasing CA199 level could imply a condition related to the pancreas, which aligns with the abdomen sonography conducted on 2023-02-09 suggesting suspected fatty infiltration of the pancreas? The latest lab results from 2023-06-26 showed normal readings in CBC, electrolytes, and renal and liver functions. The dosage of irinotecan in the FOLFIRI regimen has been increased to a regular dose (180mg/m2) during this hospitalization. No adjustments to the medication dosage are currently required.
{Left overain cacner, High grade serous carcinoma, with liver mrtastasis, s/p Debulking surgery}
[lab data]
2022-05-15 HCV Genotyping Test HCV Not Detected
2022-05-13 HCV RNA-PCR (quantative) Target Not Detected IU/mL
2022-05-12 HBsAg Nonreactive
2022-05-12 HBsAg (Value) 0.41 S/CO
2022-05-12 Anti-HBc Reactive
2022-05-12 Anti-HBc-Value 6.22 S/CO
2022-05-12 Anti-HBs 0.79 mIU/mL
2022-05-12 Anti-HCV Reactive
2022-05-12 Anti-HCV Value 15.23 S/CO
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
After reviewing the PharmaCloud and HIS5 records, no concerns were found.
The CA125 levels have been within the normal range since 2022-09-09. Following a CT scan on 2023-07-01 that indicated mild progression of liver metastasis, paclitaxel and carboplatin were reintroduced at a reduced dosage compared to their administration (x6) in 2022 Jun to Sep. The latest lab results are generally within normal limits.
{pancreatic cancer T4N1M0 stage III}
[exam findings]
2023-08-28 MRI - pancreas
2023-08-17 EGD
2023-08-13 ERCP (Endoscopic Retrograde CholangioPancreatography)
2023-05-26 MRI - pancreas
2023-02-13 MRI - pancreas
2023-02-10 PET scan
2023-01-09 T - L spine AP + Lat.
2022-12-26 ERCP (Endoscopic Retrograde CholangioPancreatography)
2022-12-23 CT - abdomen
2022-12-22 Percutaneous transhepatic gallbladder drainage, PTGBD
2022-12-22 SONO - abdomen
2022-12-07 KUB
2022-12-06 ECG
2022-10-29 CT - abdomen
2022-08-23 CT - abdomen
2022-06-23 CT - abdomen
2022-05-24 KUB
2022-04-11 CT - abdomen
2022-02-21 KUB
2022-02-16 KUB
2022-01-24 ERCP (Endoscopic Retrograde CholangioPancreatography)
2022-01-14 CT - liver, spleen, biliary duct, pancreas
2022-01-12 Patho - pancreas biopsy
2022-01-10 ERCP (Endoscopic Retrograde CholangioPancreatography)
[MedRec]
[chemotherapy] (not completed)
NS 250mL D1 + dexamethasone 4mg + palonosetron 250ug + aprepitant 150mg PO + lorazepam 1mg[leukopenia]
The WBC count hit its lowest point in 2023 on 2023-10-26 at 1.97K/uL. The latest administration of the chemotherapy drug carboplatin took place on 2023-10-04, while the most recent radiotherapy session was on 2023-10-06. Both chemotherapy and radiotherapy can lead to leukopenia.
Granocyte (lenograstim) has been prescribed to address the leukopenia, which is an undisputed intervention measure.
[timely medication switch resolves creatinine spike]
There was an increase in serum creatinine levels in late Sep compared to earlier baseline data. The cisplatin administered on 2023-09-12 was changed to carboplatin on 2023-09-26. Currently, a decrease in creatinine levels is being observed, indicating that the change in medication appears to have been a timely decision.
After reviewing both the PharmaCloud database and the HIS5 records, no reconciliation issues were identified.
After the initiation of FOLFIRINOX + pembrolizumab in 2022-02, the CEA level had been remained in the single digits between 2022-06 and 2023-02.
Then platinum-based CCRT was initiated in early 2023-09, and there was a slight decrease in the double-digit CEA level.
Based on the lab results from 2023-09-25, both AST and ALT readings are < 2x ULN (silymarin in use), with an eGFR of 55. Therefore, there is no need for medication dose adjustment.
Our gastroenterologist prescribed a two-month supply of Nexium (esomeprazole) on 2023-08-17, however the drug is currently absent from the active medication list. Please verify whether this drug is no longer needed for the patient’s condition.
[lab data]
2023-08-03 RPR/VDRL Nonreactive
2023-08-03 HBsAg Nonreactive
2023-08-03 HBsAg (Value) 0.31 S/CO
2023-08-03 Anti-HCV Nonreactive
2023-08-03 Anti-HCV Value 0.11 S/CO
2023-08-03 HIV Ab-EIA Nonreactive
2023-08-03 Anti-HIV Value 0.09 S/CO
2023-08-03 Anti-HBc Nonreactive
2023-08-03 Anti-HBc-Value 0.11 S/CO
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[immunochemotherapy]
[withhold doxirubicin until heart problems are ruled out]
Based on the PharmaCloud database, no medication discrepancies were found.
Given that the ECG from 2023-10-24 indicated atrial fibrillation with rapid ventricular response, incomplete right bundle branch block, and nonspecific ST abnormality, it may be prudent to temporarily suspend the use of doxorubicin in the planned R-miniCHOP until cardiac symptoms improve.
On 2023-09-06, our endocrinologist provided a repeat prescription for Crestor (rosuvastatin), Kentamin (Vit B1, B6, B12), Sevikar (amlodipine, olmesartan), Trajenta (linagliptin), and Uformin (metformin) to manage the patient’s existing conditions, these drugs are currently in use. Since this hospital stay, blood glucose levels have consistently ranged from 120 to 200 mg/dL. There are no inconsistencies in medication.
Recent lab results indicate that the WBC count remains above 3K/uL and there is no evidence of tumor lysis syndrome. While the LDH level remains in the normal range, the B2 microglobulin level reached 3646 ng/mL in mid-Sep. There’s no need to adjust the dose of the current medications, as the patient’s kidney and liver function tests are within normal limits.
No recent lab results for LDH or beta-2-microglobulin were found in HIS5. If needed, initiate testing to establish a baseline prior to treatment.
[lab data]
Bone marrow cell morphology and cell count - 2023-10-24 Clinical
diagnosis AML
- 2023-10-24 Gross: Marrow +
- 2023-10-24 Cellularity Hyper-mod.
- 2023-10-24 Fat componemt -
- 2023-10-24 Megakaryocyte dist absent.
- 2023-10-24 M/E ↑
- 2023-10-24 M/E(/) 95/5
- 2023-10-24 sites lliac. post. R
- 2023-10-24 type Aspiration
- 2023-10-24 specimen condition adequate
- 2023-10-24 smear good
- 2023-10-24 Myeloblast 81 %
- 2023-10-24 N.Myeloblast 0 %
- 2023-10-24 N.Meta 1,5 %
- 2023-10-24 N.Band 2.5 %
- 2023-10-24 N.Seg. 3.0 %
- 2023-10-24 Eo.Myeloblast 0 %
- 2023-10-24 Eo.Meta 0 %
- 2023-10-24 Eo.Band 0 %
- 2023-10-24 Eo.Seg. 0 %
- 2023-10-24 Baso 0 %
- 2023-10-24 Promyelo. 0 %
- 2023-10-24 Mono. 1 %
- 2023-10-24 Mo.blast 2 %
- 2023-10-24 Mo.promono. 0 %
- 2023-10-24 Mo.mature 0 %
- 2023-10-24 Lympho 0 %
- 2023-10-24 Lym.blast 0 %
- 2023-10-24 Lym.promono. 0 %
- 2023-10-24 Lym.mature 3 %
- 2023-10-24 Plasma Cell 0 %
- 2023-10-24 Pro-eyth. B 0 %
- 2023-10-24 Normoblast 0 %
- 2023-10-24 Nor.Baso 0 %
- 2023-10-24 Nor.polych 0 %
- 2023-10-24 Nor.ortho. 4 %
- 2023-10-24 Peroxidase Positive
- 2023-10-24 LAP -
- 2023-10-24 CAE Positive
- 2023-10-24 ANAE Negative
- 2023-10-24 Iron stain -
- 2023-10-24 PAS -
- 2023-10-24 Other stains -
- 2023-10-24 Description AML
- 2023-10-24 Comments AML CAE positive
Hepatitis B and C - 2023-10-23 HBsAg Nonreactive
- 2023-10-23 HBsAg (Value) 0.74 S/CO
- 2023-10-23 Anti-HBc Reactive
- 2023-10-23 Anti-HBc-Value 4.40 S/CO
- 2023-10-23 Anti-HBs 356.92 mIU/mL
- 2023-10-23 Anti-HCV Nonreactive
- 2023-10-23 Anti-HCV Value 0.13 S/CO
[exam findings]
[MedRec]
[initiating posaconazole treatment]
According to the Sanford Guide, posaconazole should be administered with a loading dose of 300 mg BID for two doses, then switching to a maintenance dose of 300 mg QD.
[lab data]
2023-10-25 HBV DNA-PCR (quantitative) 143000 IU/mL
2023-10-24 Anti-HBs 0.66 mIU/mL
2023-10-24 HBsAg Reactive
2023-10-24 HBsAg (Value) 222.81 S/CO
2023-10-24 Anti-HCV Nonreactive
2023-10-24 Anti-HCV Value 0.08 S/CO
2023-07-29 Anti-HBc Reactive
2023-07-29 Anti-HBc-Value 6.96 S/CO
2023-06-30 HLA A-high 11:01
2023-06-30 HLA A-high 33:03
2023-06-30 HLA B-high 46:01
2023-06-30 HLA B-high 58:01
2023-06-30 HLA C-high 01:02
2023-06-30 HLA C-high 03:02
2023-06-30 HLA DQ-high 02:01
2023-06-30 HLA DQ-high 03:03
2023-06-30 HLA DR-high 03:01
2023-06-30 HLA DR-high 09:01
2023-06-08 HBsAg (NM) Negative
2023-06-08 HBsAg Value (NM) 0.652
2023-06-08 Anti-HCV (NM) Negative
2023-06-08 Anti-HCV Value (NM) 0.076
2023-06-07 Aspergillus Ag Negative
2023-06-07 Aspergillus Ag Value 0.07 Ratio
[exam findings]
[MedRec]
[consultation]
[note]
Prevention of Hepatitis B Reactivation During Immunosuppressive Therapy - 2023-10-25 - https://www.hepatitis.va.gov/hbv/reactivation-prevention.asp
| Medication Class | Agents |
|---|---|
| TACE: Trans arterial chemoembolization, HCC: Hepatocellular carcinoma | Doxorubicin Epirubicin (USED in TACE for HCC) |
| B-cell depleting agents | Obinutuzumab, Ocrelizumab, Ofatumumab, Rituximab |
| Anthracycine derivatives | Doxorubicin, Epirubicin (USED in TACE for HCC) |
| TNF inhibitors | Adalimumab, Certolizumab, Etanercept, Infliximab |
| Other cytokine inhibitors and integrin inhibitors | Abatacept, Mogamulizumab, Natalizumab, Ustekinumab, Vedolizumab |
| Tyrosine kinase inhibitors | Imatinib, Nilotinib |
| Proteasome inhibitors | Bortezomib, Carfilzomib, Ixazomib |
| Traditional immunosuppressive agents | Azathioprine, 6-Mercaptopurine, Methotrexate |
| Corticosteroids | Prednisone, Prednisolone, Methylprednisone, Dexamethasone |
| Medication Class | HBsAg+, HBcAb+ | HBsAg-, HBcAb+ |
|---|---|---|
| B cell depleting agents | High risk; Use prophylaxis | High risk; Use prophylaxis |
| Anthracycine derivatives | High risk; Use prophylaxis | Moderate risk; Use prophylaxis |
| Corticosteroids ≥ 10 mg/day for ≥ 4 weeks | High risk; Use prophylaxis | Moderate risk; Use prophylaxis |
| Corticosteroids < 10 mg/day for ≥ 4 weeks | Moderate risk; Use prophylaxis | Low risk; No prophylaxis; Monitor HBsAg, HBV DNA, ALT every 3 months |
| HCC treatments: TACE, Surgical resection or Immunotherapy | High risk; Use prophylaxis | Lack of data; Use Prophylaxis |
| HCC: Local Ablation, Systemic therapies | Moderate risk; Use prophylaxis | Lack of data; Use Prophylaxis |
| TNF inhibitors | Moderate risk; Use prophylaxis | Moderate risk; Use prophylaxis |
| Other cytokine inhibitors and integrin | Moderate risk; Use prophylaxis | Moderate risk: Use prophylaxis |
| Tyrosine kinase inhibitors | Moderate risk; Use prophylaxis | Moderate risk; Use prophylaxis |
| Proteasome inhibitors | Moderate risk; Use prophylaxis | Moderate risk; Use prophylaxis |
| Traditional immunosuppressive agents | Low risk; No prophylaxis; Monitor HBV DNA, ALT every 3 months | Low risk; No prophylaxis; Monitor HBsAg, HBV DNA, ALT every 3 months |
| Intra-articular steroids | Low risk; No prophylaxis; Monitor HBV DNA, ALT every 3 months | Low risk; No prophylaxis; Monitor HBsAg, HBV DNA, ALT every 3 months |
| Corticosteroids: any dose for ≤ 1 week | Low risk; No prophylaxis; Monitor HBV DNA, ALT every 3 months | Low risk; No prophylaxis; Monitor HBsAg, HBV DNA, ALT every 3 months |
| Nucleos(t)ide Analogue | QD Dose | Potential Side Effects | Use in HIV | Lowest CrCl Without Dose Adjustment | Renal Dose Reductions (CrCl, mL/min) |
|---|
[chemotherapy]
FLAI (Fludarabine 25 mg/sqm/day days 1–5, Ara-C 2 gr/sqm/day days 1–5, Idarubicine 10 mg/sqm/day days 1, 3, 5) https://ashpublications.org/blood/article/106/11/1857/137804/Fludarabine-Based-Regimen-FLAI-Is-an-Effective https://doi.org/10.1182/blood.V106.11.1857.1857
The FLAI regimen is given as follows: (2023-10-25 GBard)
The FLAI regimen is used as an induction treatment for newly diagnosed patients with Acute Myeloid Leukemia (AML), except acute promyelocytic leukemia (APL). The regimen includes the following drugs: (2023-10-25 BingChat https://ashpublications.org/blood/article/104/11/878/75705/Efficacy-and-Toxicity-of-FLAI-vs-ICE-for-Induction https://doi.org/10.1182/blood.V104.11.878.878)
FLAI Regimen Dosing and Schedule: (2023-10-25 ChatGPT)
Fludarabine, Cytarabine, and Attenuated-Dose Idarubicin (m-FLAI) 2023-10-25 https://doi.org/10.1182/blood.V118.21.3626.3626
[HBV reactivation]
Hepatitis B virus (HBV) that has been reactivated is treated with the medication Baraclude (entecavir) today.
[HRP > Patient Safety Incident Notification > Medication Incident - HBV reactivation]
Patient medical record No. 700013816.
The lab results from 2023-07-29 indicated a reactive Anti-HBc, but there were no previous Anti-HBc test results for reference. Multiple chemotherapy sessions were administered on 2023-06-20 (standard 7+3), 2023-07-28, 2023-07-31, 2023-09-19, and 2023-09-23 (FLAI), both before and after this test result.
Due to the lack of timely preventive measures to counteract the potential reactivation of HBV infection, which can be triggered by the immunosuppressive effects of the treatment, reactivated hepatitis developed. As a response to this event, Baraclude (entecavir) was added to the patient’s active medication list on 2023-10-25.
2023-10-25 HBV DNA-PCR (quantative) 143000 IU/mL
2023-10-24 ALT 1986 U/L
2023-10-23 ALT 2487 U/L
2023-10-23 ALT 2645 U/L
2023-10-20 ALT 44 U/L
2023-10-17 ALT 37 U/L
2023-10-06 ALT 52 U/L
2023-10-24 AST 1635 U/L
2023-10-23 AST 3211 U/L
2023-10-23 AST 3758 U/L
2023-10-20 AST 36 U/L
2023-10-17 AST 27 U/L
2023-10-06 AST 28 U/L
2023-07-29 Anti-HBc Reactive
2023-07-29 Anti-HBc-Value 6.96 S/CO
There are multiple clinical practice guidelines that offer a approach to screening and managing hepatitis B virus (HBV). For example, the American Society of Clinical Oncology (ASCO) guideline recommends that all patients who are about to start systemic anticancer therapy be tested for HBV. Patients with chronic HBV who are receiving systemic anticancer therapy should receive antiviral prophylaxis throughout the course of treatment and for at least 12 months afterwards.
Ref: Hepatitis B Virus Screening and Management for Patients With Cancer Prior to Therapy: ASCO Provisional Clinical Opinion Update. J Clin Oncol. 2020 Nov 1;38(31):3698-3715. doi: 10.1200/JCO.20.01757. Epub 2020 Jul 27. PMID: 32716741.
[tube feeding - Concor]
[assessment]
Since the start of Hydrea (hydroxyurea) treatment on 2023-06-02, there has been a noticeable reduction in the patient’s WBC count from a peak of 105K/uL. However, along with this, It is also seen a concurrent suppression of the patient’s HGB and PLT levels, despite the administration of blood transfusions on 2023-06-01 and 2023-06-05.
2023-06-06 WBC 66.82 x10^3/uL
2023-06-05 WBC 99.17 x10^3/uL
2023-06-04 WBC 105.86 x10^3/uL
2023-06-03 WBC 105.55 x10^3/uL
2023-06-02 WBC 100.28 x10^3/uL
2023-06-01 WBC 75.10 x10^3/uL
2023-06-06 HGB 7.8 g/dL
2023-06-05 HGB 7.9 g/dL
2023-06-04 HGB 6.9 g/dL
2023-06-03 HGB 7.4 g/dL
2023-06-02 HGB 7.0 g/dL
2023-06-01 HGB 6.3 g/dL
2023-06-06 PLT 44 x10^3/uL
2023-06-05 PLT 62 x10^3/uL
2023-06-04 PLT 37 x10^3/uL
2023-06-03 PLT 43 x10^3/uL
2023-06-02 PLT 47 x10^3/uL
2023-06-01 PLT 63 x10^3/uL
2023-06-06 lab Cre 2.63mg/dL, eGFR 25.72, CrCl 27. Tarcocid (teicoplanin) for CrCl <30 mL/minute:
The maintenance dose, which stands at 700mg Q3D, is equivalent to 9.5 mg/kg. This is within the reasonable therapeutic range.
[lab data]
2023-10-11 Anti-HBc Nonreactive
2023-10-11 Anti-HBc-Value 0.38 S/CO
2023-10-11 Anti-HBs 53.10 mIU/mL
2023-10-11 HBsAg Nonreactive
2023-10-11 HBsAg (Value) 0.35 S/CO
2023-10-11 Anti-HCV Nonreactive
2023-10-11 Anti-HCV Value 0.28 S/CO
[exam findings]
[MedRec]
[consultation]
[immunochemotherapy]
[tube feeding]
Const-K 750mg is an extended-release tablet that contains 10 mEq of potassium. One Const-K tablet provides less potassium than a single banana (which contains about 2.2 mEq/inch or 0.9 mEq/cm).
The tablet can be crushed into fine particles and swallowed with water if injectable potassium supplementation is not preferred.
[elevated PCT and CRP]
On 2023-10-24, lab results showed a moderate amount of gram-positive cocci bacteria, gram-negative bacteria, and gram-positive rods in the (sputum) sample, as well as a high number of neutrophils and a low number of epithelial cells. PCT and CRT levels were also elevated and continued to rise over these 2 days (2023-10-24 and 2023-10-25). After consultation with an infectious disease specialist, cefepime was started on 2023-10-24 and is currently being administered.
2023-10-25 Procalcitonin(PCT) 3.67 ng/mL
2023-10-24 Procalcitonin(PCT) 0.12 ng/mL
2023-10-25 CRP 10.5 mg/dL
2023-10-24 CRP 6.7 mg/dL
G(+) Cocci 2+, GNB 2+, GPB 4+, Neutrophil/LPF > 25, Epithilial cell/LPF < 10
The patient’s white blood cell count has passed its nadir on 2023-10-23 and returned to normal. The recovery of the patient’s immune system should help them fight off bacterial infections.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[elevated bilirubin level with high DBI to TBI ratio]
Lab bilirubin level:
2023-10-20 Bilirubin total 1.14 mg/dL
2023-10-20 Bilirubin direct 0.48 mg/dL
2023-10-20 DBI/TBI 42.11 %
2023-10-13 Bilirubin total 1.30 mg/dL
2023-10-13 Bilirubin direct 0.54 mg/dL
2023-10-13 DBI/TBI 41.54 %
The direct and total bilirubin levels on 2023-10-20 appear to be slightly lower than those on 2023-10-13. Despite this decrease, the ratio of direct bilirubin (DBI) to total bilirubin (TBI) continues to be elevated, which could typically signify issues with the liver’s capacity to secrete bilirubin into the bile or an obstruction within the bile ducts, leading to a buildup of conjugated bilirubin in the bloodstream. It’s noteworthy that oxaliplatin, a component of the FOLFOX regimen, is linked to a 13% incidence of increased serum bilirubin. However, it’s been over a month since the last FOLFOX cycle was administered during the previous hospitalization.
[hypocalcemia]
corrected calcium level for hypoalbuminemia
injectable calcium supplements with Bfluid
Two injectable calcium supplements are available from stock: Vitacal (calcium chloride, equivalent to 5.44 mEq/amp) and Calglon (calcium gluconate, equivalent to 4.65 mEq/amp).
Bfluid 1000 mL contains 5 mEq of calcium per liter and can be supplemented with a maximum of an additional 5 mEq of calcium per liter.
[leukopenia, anemia]
FOLFOX regimen was administered on 2023-08-09 and 2023-09-11, there was no observed leukopenia (WBC < 3K/uL) since 2023-08-25, however, there was still anemia (HGB < 8mg/dL) observed on 2023-09-11.
2023-09-11 WBC 3.72 x10^3/uL
2023-09-07 WBC 5.61 x10^3/uL
2023-09-04 WBC 6.04 x10^3/uL
2023-08-31 WBC 8.23 x10^3/uL
2023-08-28 WBC 22.74 x10^3/uL
2023-08-25 WBC 8.85 x10^3/uL
2023-08-23 WBC 1.87 x10^3/uL 2023-08-21 WBC 1.08 x10^3/uL
2023-08-17 WBC 2.59 x10^3/uL * 2023-08-14 WBC 1.60 x10^3/uL **
2023-08-09 WBC 3.03 x10^3/uL
2023-08-07 WBC 3.90 x10^3/uL
2023-08-01 WBC 7.93 x10^3/uL
2023-09-11 HGB 7.9 g/dL 2023-09-07 HGB 9.3 g/dL 2023-09-04 HGB 10.3 g/dL 2023-08-31 HGB 8.6 g/dL 2023-08-28 HGB 9.7 g/dL 2023-08-25 HGB 9.3 g/dL 2023-08-23 HGB 10.2 g/dL 2023-08-21 HGB 8.1 g/dL 2023-08-17 HGB 7.9 g/dL 2023-08-14 HGB 8.0 g/dL * 2023-08-09 HGB 9.1 g/dL 2023-08-07 HGB 9.6 g/dL 2023-08-01 HGB 12.4 g/dL
A blood transfusion was performed on 2023-09-11 without a problem.
[Astragalus Root]
The patient has been consistently using Astragalus Root since starting chemotherapy (2023-07-25 Onc Opd). To assess whether Astragalus Root might impact the effectiveness of chemotherapy, a literature search was conducted, and a relevant article was found: “Meta-Analysis of Astragalus-Containing Traditional Chinese Medicine Combined With Chemotherapy for Colorectal Cancer: Efficacy and Safety to Tumor Response. Front Oncol. 2019;9:749. Published 2019 Aug 13. doi:10.3389/fonc.2019.00749”
Here is a summary of the key points from the research article:
Based on the findings of this study, there is currently no evidence to suggest that the patient should discontinue the use of Astragalus Root.
Leukopenia was observed on 2023-03-08, approximately 2 weeks after the patient received her first cycle of FLOT regimen chemotherapy, which started on 2023-02-24. The patient then received Granocyte (lenograstim 250ug) for three consecutive days (since 2023-03-08) and has not experienced any further episodes of leukopenia.
According to a study, preoperative FLOT chemotherapy appears to be safe and feasible for the treatment of resectable locally advanced gastric cancer. The FLOT regimen used in the study consisted of docetaxel (60 mg/m2), oxaliplatin (85 mg/m2), leucovorin (200 mg/m2), and 5-fluorouracil (2,600 mg/m2 as a 24 hr infusion). The study suggests that FLOT may be more effective in reducing morbidity and improving overall survival compared to initial surgery followed by chemotherapy. The patient received a reduced version of the FLOT regimen, which includes docetaxel 35mg/m2, oxaliplatin 75mg/m2, leucovorin 200mg/m2, and fluorouracil 2600mg/m2. (ref: Docetaxel, oxaliplatin, leucovorin, and 5-fluorouracil (FLOT) as preoperative and postoperative chemotherapy compared with surgery followed by chemotherapy for patients with locally advanced gastric cancer: a propensity score-based analysis. Cancer Manag Res. 2019;11:3009-3020. Published 2019 Apr 10. doi:10.2147/CMAR.S200883).
The dose used in this patient was lower than what is recommended in our in-hospital “Prescription Collection of Chemotherapy for Gastric Cancer” protocol (dated 2022-06-21). The protocol recommends a dose of docetaxel 50 mg/m2 IV D1, oxaliplatin 85 mg/m2 IV D1, and 5-FU 1200 mg/m2 IV continuous infusion (over 24 hours daily) on D1 and D2.
There is no need to adjust the dosage at this time. It is recommended to continue monitoring the patient’s blood cell counts to evaluate the response after the second cycle of treatment.
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
[grade 3 diarrhea]
The patient experienced grade 3 diarrhea (characterized by an increase of seven or more stools per day over baseline, the patient had a total of 8 bowel movements on 2023-10-23). However, the last administration of docetaxel, known to cause diarrhea in 23% to 43% of cases (with severe cases being <=6%), occurred almost two months ago, on 2023-08-28. This timeline makes it improbable that the recent severe diarrhea was solely a result of the previous docetaxel treatment.
Currently, the patient is on both loperamide and buscopan to manage the symptoms.
Additionally, it’s important to note that the patient’s current medication, abemaciclib, can also induce diarrhea. It’s advisable to temporarily discontinue abemaciclib until the diarrhea subsides to <= grade 1, after which the medication can be cautiously reintroduced.
[exam findings]
[chemoimmunotherapy]
R-DHAP (Rituximab, dexamethasone, high dose cytarabine, cisplatin) - DLBCL Salvage regimens - 2023-06-13 https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients
R-DHAP - Cisplatin, Cytarabine and Dexamethasone +/- Rituximab - ref https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2018/11/RDHAP.pdf
R-CHOP/R-DHAP (Rituximab + Cyclophosphamide + Doxorubicin + Vincristine + Prednisone + Dexamethasone + Cytarabine + Cisplatin) is a Chemotherapy Regimen for Lymphoma, Mantle Cell - 2023-06-13 https://www.chemoexperts.com/rchop-rdhap-mcl.html
R-CHOP
R-DHAP
Goals of therapy:
Schedule
Side Effects (omitted, please refer to the original document)
Monitoring (omitted, please refer to the original document)
Regimen Reference Order - LYMP - R-CHOP alternating with R-DHAP - 2023-10-24 - https://www.cancercare.mb.ca/export/sites/default/For-Health-Professionals/.galleries/files/treatment-guidelines-rro-files/regimen-reference-orders/lymphoproliferative-disorders/LYMP-R-CHOP-alternating-with-R-DHAP.pdf
[reconciliation]
Per the PharmaCloud records, the patient hasn’t attended any medical consultations at different hospitals recently, only having appointments with a hematologist/oncologist at the present hospital. Also, there appear to be no inconsistencies in the medication records.
[R-CHOP/R-DHAP - dose adjustment for renal impairment]
The treatment initiated in 2023-04, alternating between R-CHOP and R-DHAP, appears to be yielding positive results. A PET scan from 2023-09-21, shows a reduction in the intensity of previously identified FDG avid lesions across various lymph node regions on both sides of the diaphragm. Additionally, there’s a noticeable decrease in FDG uptake in specific areas of the right lung, indicating a partial response to the therapy.
However, lab data over the past 6 months reveals a concerning trend: the patient’s eGFR has been on a notable decline, with recent measurements approximately half of what they were initially.
If the patient’s renal function continues to decline, it might be necessary to consider dose adjustments for certain elements within the R-CHOP/R-DHAP regimen. The following are the recommended modifications:
Lab data:
Regimen administered:
The patient, who has been diagnosed with mantle cell lymphoma, is currently receiving an alternating regimen of R-CHOP and R-DHAP. The most recent cycle of R-CHOP began on 2023-06-19, and the latest cycle of R-DHAP just started today on 2023-07-11.
The lowest point of the patient’s white blood cell count (nadir) occurred on 2023-07-04, when it was recorded at 2.16K/uL. On both 2023-07-04 and 2023-07-06, the patient was administered a dose of Granocyte (lenograstim 250ug). The white blood cell count has significantly recovered by 2023-07-11, reaching 9.14K/uL, which should not hinder the delivery of the R-DHAP regimen.
Lab data revealed an episode of leukopenia on 2023-06-08 with a WBC of 1.3K/uL. This was managed with a consecutive 3 day course of Granocyte (lenograstim 250ug). The leukopenia is believed to be related to the R-DHAP treatment administered on 2023-05-24, approximately 2 weeks prior to the identified episode. In addition, the first administration of R-CHOP on 2023-04-20 also resulted in a decrease in the WBC count, which reached its lowest level on 2023-05-02. Currently, the patient is not experiencing leukopenia. Instead, he is experiencing leukocytosis.
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
2023-10-13 - docetaxel 35mg/m2 60mg NS 200mL 1hr
2023-09-23 - docetaxel 35mg/m2 60mg NS 200mL 1hr
2023-08-30 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)
2023-08-23 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)
2023-08-08 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)
2023-07-27 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)
2023-07-20 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)
2023-04-21 - topotecan 1.2mg/m2 2mg NS 40mL 0.5hr
2023-04-07 - topotecan 1.2mg/m2 2mg NS 40mL 0.5hr
2023-03-22 - topotecan 1.2mg/m2 2mg NS 40mL 0.5hr
2023-03-08 - topotecan 0.75mg/m2 1.25mg NS 40mL 0.5hr
2023-02-20 - topotecan 0.75mg/m2 1.25mg NS 40mL 0.5hr
2023-02-06 - topotecan 1.2mg/m2 2mg NS 40mL 0.5hr
2022-10-25 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 250mg NS 250mL 1hr
2022-10-04 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 240mg NS 250mL 1hr
2022-09-13 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 250mL 1hr
2022-08-01 - [liposome doxorubicin 35mg/m2 60mg D5W 250mL + carboplatin AUC 5 450mg NS 250mL] IP 90min (HIPEC)
2022-07-04 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 250mL 1hr
2022-06-13 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 250mL 1hr
2022-05-17 - paclitaxel 160mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 250mL 1hr
Lab data
2023-10-23 Neutrophil 80.6 %
2023-10-23 WBC 5.01 x10^3/uL
2023-10-23 HGB 7.8 g/dL
2023-10-23 PLT 295 *10^3/uL
2023-10-23 Albumin(BCG) 2.8 g/dL
2023-10-23 Creatinine 1.14 mg/dL
2023-10-23 eGFR 48.87 ml/min/1.73m^2
The patient has anemia, hypoalbuminemia, and altered renal function (calculated CrCl 44 mL/min).
If the patient is scheduled to receive the same dose of docetaxel as before, there is no need to adjust the dose for any degree of kidney dysfunction. However, anemia (and/or hypoalbuminemia with edema) may need to be treated before chemotherapy can begin.
[leukopenia]
Lab data showed leucopenia on 2023-10-05 at 2.26K/uL.
The most recent chemotherapy treatments prior to the leukopenia event were docetaxel (35mg/m2 60mg) on 2023-09-23 and carboplatin (AUC 2 100mg) on 2023-08-30, the latter as part of CCRT.
According to the updated lab data in WBC level, there is no more leukopenia occurs after the event.
The hype of WBC level after the leukopenia event might be due to Granocyte (lenograstim 250ug) x 4 days since 2023-10-05.
MgO, metformin, linagliptin, aspirin, trichlormethiazide, bisoprolol, olmesartan, rosuvastatin, and quetiapine were prescribed at NTUH on 2023-07-28 as a repeat prescription. These drugs were refilled on 2023-08-18, and with the exception of MgO, which might no longer be necessary, all the other drugs have been added to the active medication list.
[MedRec]
This patient is in the hospital to have his gastrointestinal problems examined further. He is currently taking the medications prescribed by our urologist and cardiologist on 2023-09-27, and there are no discrepancies with these drugs.
{High grade serous carcinoma FIGO stage IIIC, right ovarian cancer with peritoneal seeding s/p operation} (not completed)
[lab data]
[exam findings] (not completed)
[consultation]
[surgical operation]
[chemoimmunotherapy] (not completed)
2023-10-19
2023-09-13
2023-08-17
2023-07-24
2023-06-29
2023-05-31
2023-04-26
2023-03-08
2023-02-03
2022-12-20
2022-11-29
2022-10-24
2022-09-12
2022-08-12
2022-07-19 - bevacizumab 7.5mg/kg 1.5hr + paclitaxel 175mg/m2 3hr + carboplatin 600mg 2hr
2022-06-27 - bevacizumab 7.5mg/kg 1.5hr + paclitaxel 175mg/m2 3hr + carboplatin 600mg 2hr
2022-06-01 - bevacizumab 7.5mg/kg 1.5hr + paclitaxel 175mg/m2 3hr + carboplatin 600mg 2hr
2022-05-04 - paclitaxel 160mg/m2 3hr + carboplatin 600mg 2hr
Ovarian Cancer Continue Including Fallopian Tube Cancer and Primary Peritoneal Cancer, NCCN Evidence Blocks, Version 1.2022 - January 18, 2022, p42,43
Lab results 2022-07-19 indicated liver and kidney function, CBC, WBC DC, electrolytes were grossly normal. TPR, PB during this hospitalization is relatively stable.
No BRCA1/2 lab results were found. Patients with BRCA1/2-mutated clear cell carcinoma or carcinosarcoma may benefit from maintenance therapy with PARPi (poly ADP ribose polymerase inhibitor) if CR or PR is achieved after primary treatment with surgery and platinum-based first-line therapy
[exam findings] (not completed)
[MedRec]
[chemotherapy]
FOLFIRINOX chemotherapy for metastatic pancreatic cancer - 2023-10-20 - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571
Modified FOLFIRINOX chemotherapy for pancreatic cancer - 2023-10-20 - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546
According to PharmaCloud records, the patient has not visited any other hospitals in the past three months, and no discrepancies in medication have been identified.
A general urine test conducted on 2023-10-19 revealed sediment RBC 50-99/HPF and Bacteria 1+, potentially indicating the presence of urinary tract infections (UTIs) that may require further intervention.
The patient underwent a total of 12 cycles of a modified FOLFIRINOX regimen for her pancreatic tail cancer from 2022-10 to 2023-04. A new treatment protocol of gemcitabine + nab-paclitaxel was initiated on 2023-06-14, with TS-1 added to the regimen on 2023-09-06. A dermatologic adverse reaction was noted on 2023-09-13. Per today’s progress note, the patient has developed oral mucositis, and there is a plan to administer Difflam (benzydamine) spray and/or Nincort (triamcinolone acetonide) oral gel. Given that triamcinolone is a synthetic corticosteroid, its prolonged use can lead to side effects, including oral fungal infections (thrush), taste alterations, and, in rare instances, adrenal suppression. Therefore, it’s recommended to employ the lowest effective dose.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[hypokalemia, hypomagnesemia, hypoalbuminemia, hypocalcemia]
Lab data:
KCl and MgSO4 were given intravenously to treat hypokalemia and hypomagnesemia without any problems.
Lab results from 2023-10-18 indicated Ca 1.68 mmol/L, Albumin 2.8 g/dL. An estimated corrected serum calcium of 7.7 mg/dL, equivalent to 1.9 mmol/L, which is still beneath the normal range. Considering calcium and albumin supplements could be an optional course of action.
[severe delayed vomiting]
Severe vomiting persisted after the previous chemotherapy session (from 2023-09-04 to 2023-09-06), became intolerable, and led the patient to seek emergency care at our hospital on 2023-09-14. This type of vomiting is likely post-chemotherapy delayed vomiting.
For chemotherapy-induced delayed vomiting, NK-1 receptor antagonists (NK-1 RAs) may be preferred over 5-HT3 receptor antagonists (5-HT3 RAs). NK-1 RAs inhibit the effects of substance P, a neurotransmitter involved in vomiting, especially during the delayed phase. While 5-HT3 RAs block serotonin receptors and are most effective in the acute phase.
A study published in BMC Cancer found that the prolonged use of an NK-1 RA (fosaprepitant) in addition to a 5-HT3 RA and dexamethasone was more effective in preventing delayed Chemotherapy-Induced Nausea and Vomiting (CINV) compared to a regular dosage. The study showed a statistically significant lower incidence of nausea and slightly lower incidence of grade 1 vomiting in the delayed phase. Ref: https://bmccancer.biomedcentral.com/articles/10.1186/s12885-023-11070-3
Our hospital stocks Akynzeo, which includes netupitant, the NK-1 RA with the longest half-life at 96 hours.
[diagnosis] - 2023-03-10 admission note
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
2023-10-18 - (FOLFIRINOX)
2023-09-19 - (FOLFIRINOX)
2023-08-29 - (FOLFIRINOX)
2023-07-11 - (FOLFIRINOX)
2023-06-21 - (FOLFIRINOX)
2023-05-31 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)
2023-05-10 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)
2023-04-25 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)
2023-04-11 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)
2023-03-10 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX, Covorin NS 500 -> 250mL)
2023-02-23 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)
2023-02-02 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)
Granocyte (lenograstim 250ug) CGRAN01
WBC
[reconcilation]
The patient had an appointment at Tri-Service General Hospital on 2023-09-23 and received prescriptions for Trajenta (linagliptin), Diovan (valsartan), Certican (everolimus), and Stilnox (zolpidem), with the latter not currently being utilized. Please verify if the discontinuation of Stilnox is intentional.
As an additional note, the patient received an injection of Zoladex (goserelin acetate) at TSGH on 2023-10-06, with the previous injection administered on 2023-07-28.
This patient had an appointment at the Tri-Service General Hospital on 2023-06-24 where he was prescribed Trajenta (linagliptin), Diovan (valsartan), Certican (everolimus), and Stilnox (zolpidem). These medications have been correctly incorporated into the patient’s active medication list. No discrepancies were found during the medication reconciliation process.
This patient had an appointment at the Tri-Service General Hospital on 2023-05-05, during which he was prescribed a single dose of Zoladex (goserelin acetate 10.8mg). As the suggested administration interval for this medication is every 12 weeks, the next scheduled dose should be on 2023-07-28. No issues were discovered during the medication reconciliation process.
The patient seems to be showing signs of anemia with an increasing trend towards macrocytosis. As the bilirubin level is still within the normal range, hemolytic anemia may be less likely. A single intramuscular dose of B-Red (hydroxocobalamin 1mg) is scheduled for 2023-06-02, and folate is already included in the current FOLFIRINOX regimen. At this time, there is no concrete evidence indicating a rapid progression in the severity of anemia, so please continue monitoring.
Zoladex (goserelin acetate) 10.8mg was administered Q3M, with the most recent administration occurring on 2023-05-05, at TSGH for the management of the patient’s prostate cancer. Furthermore, antiglycemic, antihypertensive, and anti-rejection medications prescribed at TSGH are correctly reflected in the current active medication list, presenting no issues with medication reconciliation.
Please be aware, there is a slow yet noticeable upward trend in both AST and ALT lab results. This should be closely monitored for possible potential liver function impairment.
2023-05-10 S-GOT/AST 35 U/L
2023-04-25 S-GOT/AST 42 U/L
2023-04-11 S-GOT/AST 30 U/L
2023-03-28 S-GOT/AST 25 U/L
2023-03-23 S-GOT/AST 30 U/L
2023-03-09 S-GOT/AST 23 U/L
2023-02-22 S-GOT/AST 17 U/L
2023-02-15 S-GOT/AST 16 U/L
2023-01-30 S-GOT/AST 14 U/L
2023-01-13 S-GOT/AST 19 U/L
2023-05-10 S-GPT/ALT 44 U/L
2023-04-25 S-GPT/ALT 55 U/L
2023-04-11 S-GPT/ALT 36 U/L
2023-03-28 S-GPT/ALT 32 U/L
2023-03-23 S-GPT/ALT 35 U/L
2023-03-09 S-GPT/ALT 27 U/L
2023-02-22 S-GPT/ALT 21 U/L
2023-02-15 S-GPT/ALT 22 U/L
2023-01-30 S-GPT/ALT 20 U/L
2023-01-13 S-GPT/ALT 20 U/L
[exam findings] (not completed)
[MedRec]
[consultation]
[chemotherapy]
[reconciliation]
According to the PharmaCloud database, there’s no discrepancy between the previously prescribed medications.
The patient was diagnosed with BUL cancer, specifically adenocarcinoma, with metastases to both lung hila and bilateral mediastinal lymph nodes. Treatment was started on 2021-06-15 with Iressa (gefitinib) for two weeks before switching to Vizimpro (dacomitinib) from 2021-06-29.
The chest CT of 2023-09-11 showed significant disease progression in the LUL, while the RUL tumor remained stable compared to the previous CT of 2023-01-05. This may indicate disease heterogeneity and potential development of resistance in certain aspects of the disease after more than 2 years of use of Vizimpro.
{pancreatic head cancer}
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Modified FOLFIRINOX chemotherapy for pancreatic cancer 2023-05-19 https://www.uptodate.com/contents/image?imageKey=ONC%2F109546
FOLFIRINOX chemotherapy for metastatic pancreatic cancer 2023-05-19 https://www.uptodate.com/contents/image?imageKey=ONC%2F79571
[reconciliation]
The patient is currently taking the following medications, as prescribed by their urologist and endocrinologist on 2023-08-28:
There are no discrepancies noted in the patient’s medication list.
[CA199 goes up]
Please note that CA19-9 levels have been monotonically increasing in recent months. This might suggest that the disease has a tendency to gradually gain resistance.
The medications Betmiga (mirabegron) and Harnalidge (tamsulosin) and Oxbu ER (oxybutynin) prescribed by our urologist, along with Trajenta (linagliptin) prescribed by our endocrinologist on 2023-08-28, are currently being taken by the patient with no discrepancies noted.
Our endocrinologist’s repeat prescription (issued on 2023-06-05) for Trajenta (linagliptin) is currently on the active medication list, and there are no discrepancies noted.
The patient recently refilled his prescription for Trajenta (linagliptin) on 2023-07-10 for managing his T2DM. This drug is accurately included in the active medication list, with no reconciliation issues identified.
According to the PharmaCloud database, all of this patient’s medical requirements have been addressed at our hospital over the past three months. As a result, no issues with medication reconciliation have been detected.
The patient’s DM is currently managed with Trajenta (linagliptin 5mg) 1# QD. He had an increased preprandial serum glucose level of 170mg/dL on 2023-06-20 at 06:24. The most recent HbA1c level was 5.7% on 2023-05-31. This sudden rise could be a temporary fluctuation and is worth continuous monitoring.
It was noted that the blood sugar level did not exceed 180 mg/dL, which was an improvement over the prior hospital stay.
Renal sonography (2022-09-24) found bilateral renal stones, and calcium oxalate crystals in urine (2023-02-01). Primary hyperoxalurias are rare inborn errors of glyoxylate metabolism characterized by the overproduction of oxalate, which is poorly soluble and is deposited as calcium oxalate in various organs. The kidney stones in this patient should be less likely to be associated with primary hyperoxaluria.
[lab data]
2023-07-31 Anti-HBc (NM) Positive
2023-07-31 Anti-HBc Value (NM) 0.636
2023-07-31 Anti-HBs (NM) Positive
2023-07-31 Anti-HBs value (NM) 677.000 mIU/mL
2023-07-31 Anti-HCV (NM) Negative
2023-07-31 Anti-HCV Value (NM) 0.043
2023-07-25 HBsAg (NM) Negative
2023-07-25 HBsAg Value (NM) 0.418
2023-07-25 CA-199 (NM) 354.780 U/ml
2023-07-25 CEA (NM) 31.940 ng/ml
[exam findings]
[MedRec]
[chemotherapy]
[liver function]
The patient experienced a transient elevation in liver function test readings in mid-Sep, with peak values of 106 U/L for AST, 225 U/L for ALT, and 1.06 mg/dL for total bilirubin on 2023-09-18. However, the liver function test abnormalities have resolved, and there is no evidence of sustained liver injury at present.
2023-10-17 AST 33 U/L
2023-10-05 AST 21 U/L
2023-09-25 AST 45 U/L
2023-09-22 S-GOT/AST 51 U/L
2023-09-18 S-GOT/AST 106 U/L
2023-09-14 S-GOT/AST 96 U/L
2023-09-07 S-GOT/AST 31 U/L
2023-08-25 S-GOT/AST 21 U/L
2023-08-09 S-GOT/AST 29 U/L
2023-07-20 S-GOT/AST 15 U/L
2023-10-17 ALT 41 U/L
2023-10-05 ALT 25 U/L
2023-09-25 ALT 86 U/L
2023-09-22 S-GPT/ALT 110 U/L
2023-09-18 S-GPT/ALT 225 U/L
2023-09-14 S-GPT/ALT 136 U/L
2023-09-07 S-GPT/ALT 40 U/L
2023-08-25 S-GPT/ALT 17 U/L
2023-08-22 S-GPT/ALT 17 U/L
2023-08-09 S-GPT/ALT 13 U/L
2023-07-20 S-GPT/ALT 11 U/L
2023-10-17 Bilirubin total 0.61 mg/dL
2023-10-05 Bilirubin total 0.44 mg/dL
2023-09-25 Bilirubin total 0.50 mg/dL
2023-09-22 Bilirubin total 0.68 mg/dL
2023-09-18 Bilirubin total 1.06 mg/dL
2023-09-14 Bilirubin total 0.74 mg/dL
2023-09-07 Bilirubin total 0.68 mg/dL
2023-08-25 Bilirubin total 0.50 mg/dL
2023-08-22 Bilirubin total 0.40 mg/dL
2023-08-09 Bilirubin total 0.87 mg/dL
2023-07-20 Bilirubin total 1.25 mg/dL
The patient received 4 cycles of FOLFOX chemotherapy, administered on 2023-08-09, 2023-08-24, 2023-09-25, and 2023-10-17. Oxaliplatin, a drug used in FOLFOX, is associated with increased serum alanine aminotransferase (36%), increased serum alkaline phosphatase (42%), increased serum aspartate aminotransferase (54%), and increased serum bilirubin (13%). It is possible that oxaliplatin caused the elevated liver function test results in this patient.
In mid-Sep, the patient was prescribed BaoGan (silymarin), a herbal supplement that is thought to protect the liver, to mitigate the risk of liver damage.
In addition, FOLFIRI, an alternative chemotherapy regimen that contains irinotecan, is also associated with increased serum bilirubin (84%) and increased serum alkaline phosphatase (13%).
[RAS mutation detected]
Patients with colorectal cancer (CRC) who have an RAS mutation (2023-08-11 Lab result, NRAS mutation detected) are less likely to respond to targeted therapies that target EGFR. This is because NRAS mutations can activate the RAS-MAPK pathway downstream of EGFR, making the tumor resistant to anti-EGFR therapies.
The following targeted therapies are less likely to be effective in the setting of CRC with an NRAS mutation:
[MedRec]
[chemotherapy]
[leukopenia]
Based on the HIS5 lab data, a leukopenia event was recorded on 2023-10-13 with a count of 1.83K/uL (marked with an asterisk in the following table). The most recent chemotherapy administered was 500mg of fulvestrant on the same day, very close in time to the WBC data collection, leaving open the possibility that the actual medication administration occurred after the blood sample was taken. Moreover, according to UpToDate, the occurrence of neutropenia (2%; grade 3: 1%; grade 4: <1%) is relatively low compared to other chemotherapy drugs. For these two reasons, it’s less likely that this drug was the main contributor to the neutropenia observed on 2023-10-13.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
The current FOLFOX regimen was initiated on 2023-04-18, during which time multiple leukopenia events occurred (indicated in the table below with “**” for WBC < 2K/uL and “*” for WBC < 3K/uL). Since July, the regimen has eliminated the 5-FU bolus and reduced oxaliplatin from 85 mg/m2 to 75 mg/m2. Since these adjustments, there has only been one case of WBC < 2K/uL on 2023-10-05, primarily due to the intermittent administration of Granocyte (lenograstim) based on the patient’s condition. The most recent lab data (2023-10-12) showed a WBC of 4.15K/uL, indicating no current evidence of leukopenia.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
After reviewing the PharmaCloud database and the hospital’s HIS5 records, no medication reconciliation issues were identified.
The patient received a 28-day refill of rabeprazole on 2023-08-10. While the active medication list does not show any current use of PPIs, Stogamet (cimetidine) is being used. Therefore, there are no medication reconciliation concerns.
There are no medication reconciliation issues identified after reviewing the PharmaCloud database and HIS5 records.
[lab data]
2023-07-17 CMV viral load assay 6060 IU/mL
2023-07-07 CMV viral load assay 331 IU/mL
2023-04-25 MTBC PCR DETECTED CFU/ml
2023-04-25 MTBC PCR Value 10000 - 100000 CFU/ml
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
After reviewing the PharmaCloud database and the hospital’s HIS5 records, no medication reconciliation issues were identified.
[tube feeding]
As the adsorbent properties of this product may interfere with the rates and/or levels of absorption of other substances, it is recommended not to administer any other drugs at the same time as SMECTA. ref: https://www1.ndmctsgh.edu.tw/pharm/pic/medinsert/005SME01E.pdf
[hyperbilirubinemia follow-up]
2023-09-04 Bilirubin total 1.55 mg/dL
2023-08-11 Bilirubin total 1.61 mg/dL
2023-08-07 Bilirubin total 2.16 mg/dL
2023-07-17 Bilirubin total 1.43 mg/dL
2023-07-12 Bilirubin total 2.04 mg/dL
2023-07-10 Bilirubin total 2.98 mg/dL
2023-09-04 Bilirubin direct 0.74 mg/dL
2023-08-11 Bilirubin direct 0.64 mg/dL
2023-08-07 Bilirubin direct 1.03 mg/dL
2023-07-17 Bilirubin direct 0.59 mg/dL
2023-07-12 Bilirubin direct 1.06 mg/dL
2023-07-10 Bilirubin direct 1.61 mg/dL
At present, the patient’s bilirubin levels are lower than what was observed in mid-July, even after resuming AKruiT-4 on 2023-08-04.
It’s worth noting that AKruiT-4 is being administered alongside Smecta, which is not advisable. Smecta has the potential to alter the rate or level of AKruiT-4 absorption.
[optional addition of Genurso for hyperbilirubinemia]
The addition of Genurso (ursodeoxycholic acid 100mg) #1 or #2 TID might be considered to help alleviate the patient’s hyperbilirubinemia. ref: Anti-Tuberculosis Drug Induced Liver Injury and Ursodeoxycholic Acid. Journal of Tuberculosis Research, Vol.8 No.2, 2020. https://doi.org/10.4236/jtr.2020.82007
[approach to hepatotoxicity caused by antituberculous drugs]
AKuriT-4 was ceased on 2023-07-10, with bilirubin levels subsequently falling, though they still remain above twice the upper limit of normal (ULN).
As per the “Approach to hepatotoxicity caused by first-line antituberculous drugs in adults” from UpToDate (https://www.uptodate.com/contents/image?imageKey=ID%2F109447), when the bilirubin level is less than 2mg/dL and the enzyme levels are less than twice the upper limit of normal, either a regimen made up of liver-sparing drugs (like ethambutol, a fluoroquinolone or linezolid) may be considered or the gradual reintroduction of first-line agents may be done.
Another study released in the New England Journal of Medicine in 2021 titled “Four-Month Rifapentine Regimens with or without Moxifloxacin for Tuberculosis” deduced that the effectiveness of a four-month regimen based on rifapentine, with or without moxifloxacin, was not inferior to the standard six-month regimen in the treatment of tuberculosis. The manufacturer’s guidelines for rifapentine do not include suggestions for dose adjustments in patients with hepatic impairment. It is believed that the pharmacokinetics of rifapentine in patients with varying degrees of hepatic impairment are similar to those in healthy volunteers.
[following up on bilirubin and albumin levels]
[AKuriT-4 follow-up]
{not completed}
[exam findings]
2023-10-06 SONO - abdomen
2023-10-05 Abdomen - standing (diaphragm)
2023-10-02 Percutaneous Gall Bladder Drainage, PTGBD
2023-10-02 CT - abdomen
2023-10-02 ECG
2023-06-24 CT - abdomen
2023-03-30 Patho - pancreas biopsy
2023-03-30 Patho - liver biopsy needle/wedge
2023-03-28 Patho - liver biopsy needle/wedge
2023-03-17 CT - abdomen
2022-11-09 ENT SONO - head and neck soft tissue
2021-02-03 ENT SONO - head and neck soft tissue
2021-01-27 ENT Hearing Test
2018-03-19 Pure Tone Audiometry
[MedRec]
[Consultation]
[chemotherapy]
[note]
gemcitabine 2023-04-11 https://www.uptodate.com/contents/gemcitabine-drug-information
The patient’s body weight was recorded as 33.7kg on 2023-10-09. It may be prudent to monitor for potential adverse reactions as administering standard doses to underweight individuals may increase the risk of side effects.
{Neuroendocrine carcinoma}
[exam findings]
[MedRec]
[consultation]
[surigcal operation]
[chemotherapy]
According to the PharmaCloud database, there are no recent records of the patient seeking services from other medical facilities. In addition, Pentop (pentoxifylline) prescribed by our nephrologist on 2023-09-12 is currently being used without any discrepancies noted.
The 5FU bolus was omitted from the FOLFOX regimen during this hospital stay due to a reduced WBC count, recorded at 3.08K/uL on 2023-10-12.
According to PharmaCloud, there are no records of this patient seeking medical care at other facilities in the past three months. Our nephrologist has issued a repeat prescription for Pentop (pentoxifylline) to manage his CKD, and the medication is currently being used with no discrepancies identified.
[reconciliation]
On 2023-07-07, the patient renewed prescriptions for bisoprolol and valsartan. Currently, only bisoprolol is listed as an active medication, and valsartan has not been included. As the patient’s blood pressure has consistently remained within the normal range during this hospital stay, there may not be an immediate need to reintroduce valsartan. Nevertheless, it is crucial to continue monitoring the patient’s blood pressure to assess if any further adjustments to the medication regimen are necessary.
[renal function follow-up]
This month (July), compared to previous months, the serum creatinine has returned to the normal range, and currently, no medications require renal dosage adjustment.
[thrombocytopenia]
Since starting topotecan on 2023-05-12, the patient has experienced several episodes of thrombocytopenia. Blood transfusions were administered on 2023-06-14, 2023-06-28, and 2023-07-27 in response to these events. In addition, the dosage of topotecan was sequentially reduced from 2.5 mg to 2.0 mg and then to 1.8 mg. Despite these measures, thrombocytopenia has been observed to date, but no PLT less than 50K/uL has been observed.
2023-07-25 PLT 90 10^3/uL
2023-07-11 PLT 94 10^3/uL
2023-06-28 PLT 474 10^3/uL
2023-06-20 PLT 89 10^3/uL
2023-06-12 PLT 390 10^3/uL
2023-06-01 PLT 95 10^3/uL
2023-05-25 PLT 15 10^3/uL
2023-05-10 PLT 283 10^3/uL
2023-04-27 PLT 244 *10^3/uL
[reconciliation]
The patient recently renewed his prescriptions for bisoprolol and valsartan on 2023-07-07. Currently, only bisoprolol is incorporated into the active medication list, while valsartan has been left out. Given that the patient’s blood pressure measurements have consistently fallen within the normal spectrum during this hospital stay, reintroduction of valsartan may not be mandatory at this point. However, it remains important to continually monitor the patient’s blood pressure to establish whether further alterations in his medication regimen are warranted.
[reconciliation]
[thrombocytopenia]
This patient initiated topotecan therapy on 2023-05-12, with two additional cycles administered on 2023-06-06 and 2023-06-28. The platelet levels are compiled in the following table, where “*” represents PLT < 100K/uL and “**” represents PLT < 50K/uL.
Intravenous Topotecan is linked with a considerable incidence of thrombocytopenia. As per UpToDate, Grade 4 thrombocytopenia occurs in 27% to 29% of patients. The lowest point (nadir) typically occurs around day 15, and the duration of the thrombocytopenia typically lasts for 3 to 5 days.
The dose of topotecan was reduced from 2.5g to 2.0g starting from the second cycle and was further reduced to 1.8g for the last three days of the five-day administration period. This was a strategy intended to prevent further thrombocytopenia in the patient. In addition, blood transfusions were conducted on 2023-06-14 and 2023-06-28 to alleviate the impact of this side effect.
Currently, the patient’s platelet count (PLT) is slightly above the ULN. Although there are no current signs of thrombocytopenia, it remains critical for the healthcare team to regularly monitor the patient’s CBC as is standard procedure.
[reconciliation]
[assessment]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[reconciliation]
The patient was prescribed a 28-day course of Concor (bisoprolol) and Livalo (pitavastatin) at Taipei City Hospital on 2023-09-27. While the former is currently being administered, the latter does not appear on the list of active medications. Please verify that the use of pitavastatin is no longer necessary.
[hypercalcemia]
Observed hypercalcemia warrants an evaluation of the PTH level to assess the likelihood of hyperparathyroidism.
Recommended Actions:
If the initial interventions are ineffective, the following alternatives could be contemplated:
[pancytopenia]
Pancytopenia was noted in mid-Sep, likely attributed to the initiation of the doxorubicin + ifosfamide regimen on 2023-09-05, approximately 10 days after its commencement. Following treatment with a blood transfusion on 2023-09-18, and the initiation of a consecutive 5-day course of Granocyte (lenograstim) on the same day, pancytopenia has shown successful improvement.
2023-09-20 WBC 3.63 x10^3/uL
2023-09-18 WBC 0.20 x10^3/uL 2023-09-15 WBC 0.66 x10^3/uL
2023-09-11 WBC 8.43 x10^3/uL
2023-09-01 WBC 8.80 x10^3/uL
2023-09-20 HGB 10.3 g/dL 2023-09-18 HGB 7.4 g/dL ** 2023-09-15 HGB 9.4 g/dL * 2023-09-11 HGB 10.9 g/dL 2023-09-01 HGB 13.2 g/dL
2023-09-20 PLT 138 10^3/uL 2023-09-18 PLT 25 *10^3/uL ** 2023-09-15 PLT 65 *10^3/uL ** 2023-09-11 PLT 141 10^3/uL 2023-09-01 PLT 259 *10^3/uL
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
G-CSF
There were no medication reconciliation issues when reviewing PharmaCloud and HIS5 records.
[Leukemia has been managed more effectively]
Leukopenia has become less severe and less frequent following the intermittent administration of prophylactic/therapeutic Granocyte (lenograstim) in accordance with chemotherapy cycles. This approach has improved the management of this side effect.
[reconciliation]
Currently, the patient’s medication records are not accessible on PharmaCloud. However, after reviewing the HIS5 records, no medication reconciliation issues were found.
[leukopenia]
At this time, the patient is not experiencing severe leukopenia. Any leukopenia events that have occurred since the start of the [bevacizumab paclitaxel cisplatin] regimen on 2023-05-26 have been treated with G-CSF administrations without reducing the dose of paclitaxel or cisplatin.
Based on the PharmaCloud database, this patient has exclusively attended our hospital for outpatient and inpatient services across the departments of urology, obstetrics and gynecology, radiation-oncology, and hemato-oncology in the past three months. No issues were found during medication reconciliation.
[reconciliation]
[more intensive hydration]
[leukopenia]
This patient last received paclitaxel and cisplatin on 2023-05-15 and a WBC nadir of 1.16K/uL was noted on 2023-05-25. Paclitaxel carries a Boxed Warning regarding bone marrow suppression and recommends frequent peripheral blood cell counts for all patients receiving the drug. Granocyte (lenograstim 250ug) was administered for three consecutive days starting on 2023-05-25.
According to the reimbursement guidelines of the Taiwan National Health Insurance, the use of G-CSF is allowed for patients with non-hematologic malignancies who have a WBC count of less than 1000/uL or an absolute neutrophil count (ANC) of less than 500/uL after chemotherapy. This patient meets the specified criteria (neutrophil 14.7%), so G-CSF can be prescribed to manage leukopenia following this round of chemotherapy.
[diagnosis] - 2023-03-09 admission note
[past history] - 2023-03-09 admission note
[family history]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3 diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3 diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3FOLFIRINOX chemotherapy for metastatic pancreatic cancer 2023-06-06 https://www.uptodate.com/contents/image?topicKey=ONC%2F2475&imageKey=ONC%2F79571
Cycle length: 14 days.
Regimen
Modified FOLFIRINOX chemotherapy for pancreatic cancer 2023-06-06 https://www.uptodate.com/contents/image?topicKey=ONC%2F2475&imageKey=ONC%2F109546
Cycle length: 14 days.
Regimen
This patient recently refilled a 28-day supply of Urosin (atenolol) and nifedipine on 2023-08-26, and a prescription for Dicetel (pinaverium bromide), Gaslan, and Protase was refilled on 2023-08-14. While the latter group of medications has been added to the active medication list, the antihypertensive agents (atenolol and nifedipine) have not been included. Given that the patient’s blood pressure was recorded as 139/92 at 08:13 on 2023-09-19, it may be advisable to reinstate these antihypertensive drugs if the blood pressure continues to rise.
Currently, the patient’s medication records are not accessible on PharmaCloud. However, after reviewing the HIS5 records, no medication reconciliation issues were found.
The active medication list includes a repeat prescription by our gastroenterologist for Protase (pancrelipase), Dicetel (pinaverium bromide), and Gaslan (dimethylpolysiloxane). However, Urosin (atenolol) and nifedipine, which were refilled on 2023-07-26, are not currently being used as the patient’s blood pressure has not shown an elevation during this hospitalization. There are no medication reconciliation issues identified.
The local pharmacy refilled atenolol and nifedipine on 2023-07-01. They are included in the active medication list, and no medication reconciliation issues were found.
Protase (pancrelipase 280mg/cap) is properly prescribed as 1# PO BID. Pancrelipase itself has the potential to cause various gastrointestinal signs and symptoms, including but not limited to abdominal pain, abnormal stools, constipation, diarrhea, duodenitis, dyspepsia, flatulence, frequent bowel movements, gastritis, nausea, and vomiting. It is recommended to monitor these symptoms.
The patient is receiving a dose-modified FOLFIRINOX regimen, which includes a lower dose of oxaliplatin (85mg/m2 reduced to 75mg/m2) and irinotecan (180mg/m2 reduced to 150mg/m2). Despite the reduction in dosage, recent lab data shows a trend towards leukopenia, which should be closely monitored.
[exam findings]
[MedRec]
[immunochemotherapy]
Based on the PharmaCloud database, the patient has no records of visiting other clinics. Additionally, after consultations in our medical departments, no repeat prescriptions were issued, and no medication discrepancies were identified.
On 2023-09-13, a CT scan indicated a partial response after the patient underwent 4 treatment cycles (1 R-COP followed by 3 R-CHOP). The treatment appears to remain effective to date.
[lab data]
2023-02-14 Anti-HBc Nonreactive
2023-02-14 Anti-HBc-Value 0.14 S/CO
2023-02-14 Anti-HBs 0.00 mIU/mL
2023-02-14 Anti-HCV Nonreactive
2023-02-14 Anti-HCV Value 0.06 S/CO
2023-02-14 HBsAg Nonreactive
2023-02-14 HBsAg (Value) 0.33 S/CO
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
There was no medication reconciliation issue identifed.
Leukopenia (WBC 1.16K/uL) was noted on 2023-09-07, approximately 2 weeks after the patient received the paclitaxel + carboplatin regimen on 2023-08-24. With Granocyte (lenograstim) administered for 3 days in early Sep, 4 days in mid-Sep, and 4 days in late Sep, the WBC finally reached above 3K/uL. Close monitoring of the WBC count may be necessary at this time.
2023-10-04 WBC 3.15 x10^3/uL 2023-09-28 WBC 2.66 x10^3/uL 2023-09-13 WBC 3.33 x10^3/uL 2023-09-07 WBC 1.16 x10^3/uL * 2023-08-23 WBC 3.41 x10^3/uL
After examining both PharmaCloud and HIS5 records, no medication discrepancies were found.
[exam findings]
[MedRec]
[chemmotherapy]
[the possibility of fever associated with the drugs being used]
Based on UpToDate database, it’s noted that Tapimycin (piperacillin, tazobactam) and Ulstop (famotidine), which the patient is currently taking, have been reported to be associated with fever as an adverse reaction. The incidence rate for the former is 2%, while for the latter, it is less than 1%.
[Dipeptiven dosage and administration]
(Dipeptiven ref: https://www.fresenius-kabi.com/nz/documents/Dipeptiven_Datasheet.pdf)
Dipeptiven 100 mL (alanyl glutamine 20g) can be diluted with NS 250-1000 mL. After dilution, it can be stored at room temperature for 24 hours.
A maximum daily dosage of 2 g amino acids/or protein per kg bodyweight should not be exceeded in parenteral/enteral nutrition. The supply of alanine and glutamine via Dipeptiven should be taken into consideration in the calculation. The proportion of the amino acids supplied through Dipeptiven should not exceed approx. 30% of the total amino acids/protein supply.
If the patient is still on port-A, based on his body weight of about 70kg, IV infusion is recommended not less than 3 hours (20g / (0.1g/kg/hr x 70kg)), 4 to 6 hours would be even better.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
The repeat prescription for Exforge (amlodipine, valsartan), Concor (bisoprolol), and Through (sennoside) was issued by our cardiologist on 2023-08-24, and the patient refilled these medications on 2023-09-11. The medications are currently in use with no discrepancies found.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Most of the medications prescribed by our rheumatologist are immunomodulators and primarily immunosuppressive. As the patient is currently undergoing chemotherapy, it is advisable to monitor any changes in immune function or rheumatoid arthritis symptoms.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy] (not completed)
2023-09-05 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 480mg NS 250mL 2hr + fluorouracil 2400mg/m2 2850mg 46hr (FOLFIRI Q2W, 20% off)
2023-08-15 - FOLFIRI
2023-07-17 - FOLFIRI
2023-07-03 - FOLFIRI
2023-06-01 - FOLFIRI
2022-03-08 ~ 2023-01-13 - FOLFOX
2021-02-01 ~ 2021-07-27 - FOLFIRI plus bevacizumab
2021-01-18 - FOLFIRI
2014-04-03 ~ 2014-10-07 - PF, post CCRT adjuvant, 12 cycles
2014-02-10 ~ 2014-03-13 - 5-Fu based
Vemlidy (tenofovir alafenamide 25mg) 1# QD prescribed by our gastroenterologist on 2023-09-30 is currently in use. No medication discrepancy was found.
Please note that both tumor markers CA-199 and CEA have started to show a slight upward trend after bottoming out in August. This may indicate a change in the balance of the treatment and the disease.
2023-09-22 CA-199 (NM) 1277.40 U/ml 2023-08-25 CA-199 (NM) 1125.26 U/ml 2023-08-18 CA-199 (NM) 743.66 U/ml 2023-08-01 CA-199 (NM) 931.32 U/ml 2023-07-18 CA-199 (NM) 1470.34 U/ml 2023-06-20 CA-199 (NM) 867.59 U/ml
2023-09-22 CEA (NM) 96.979 ng/ml 2023-08-25 CEA (NM) 87.270 ng/ml 2023-08-18 CEA (NM) 81.753 ng/ml 2023-08-01 CEA (NM) 61.346 ng/ml 2023-07-18 CEA (NM) 98.554 ng/ml 2023-06-20 CEA (NM) 66.050 ng/ml 2023-04-25 CEA (NM) 47.692 ng/ml 2023-01-18 CEA (NM) 5.127 ng/ml 2022-10-28 CEA (NM) 5.562 ng/ml
No medication reconciliation issues were identified after reviewing the PharmaCloud database and hospital HIS5 records.
After reviewing the PharmaCloud database and in-hospital HIS5 records, no medication reconciliation issues were found.
[MedRec]
This patient has been receiving treatment at the Koo Foundation Sun Yat-Sen Cancer Center in the past. The only prescription medication from that center that is still valid to date is Megest Oral Suspension (megestrol acetate). This drug is not currently included in the active medication list. If the patient continues to experience cachexia or poor appetite, it is advisable to reintroduce this medication.
[exam findings]
[consultation]
[SOAP]
[surgical operation]
[immunochemotherapy]
The recently refilled repeat prescription for Vemlidy (tenofovir alafenamide) on 2023-07-05 is being utilized without any reconciliation issues detected.
On 2023-03-24, a Port-A was inserted for the patient who previously refused chemotherapy.
All the oral/inhaled medications in the active prescription are appropriate for his respiratory symptoms, including Sodicon (dextromethorphan), Butanyl (terbutaline), and Ipratran (ipratropium bromide).
[exam findings]
[MedRec]
[chemotherapy]
[leukopenia]
2023-09-28 WBC 5.63 x10^3/uL 2023-09-21 WBC 1.66 x10^3/uL * 2023-09-13 WBC 4.32 x10^3/uL 2023-09-05 WBC 5.12 x10^3/uL
The leukopenia observed on 2023-09-21 at 1.66K/uL occurred approximately 2 weeks after her first administration of epirubicin and cyclophosphamide. Granocyte (lenograstim 250ug) was administered for 3 consecutive days beginning on 2023-09-21.
The second dose of epirubicin and cyclophosphamide was administered on 2023-10-02 and prophylactic G-CSF was considered and prescribed in advance for 2023-10-09 to 2023-10-11 during the double tenth consecutive holidays. Leukopenia is expected to be less severe this time.
[lab data]
2023-09-13 HBV-DNA-PCR Target Not Detected IU/mL
2023-09-11 HBsAg Nonreactive
2023-09-11 HBsAg (Value) 0.49 S/CO
2023-09-11 Anti-HCV Nonreactive
2023-09-11 Anti-HCV Value 0.12 S/CO
2023-09-11 Anti-HBc Reactive
2023-09-11 Anti-HBc-Value 5.99 S/CO
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[drug identification]
Since the drug to be identified is an unpackaged tablet, its quality and expiration date cannot be confirmed, so the response is that the drug cannot be identified.
An in-hospital porter will be sent to deliver the tablets to the ward.
[exam findings]
[MedRec]
[consultation]
[tube feeding]
Concor 5mg — Please use the Simple Suspension Method (SSM) to place the tablet in warm drinking water and leave for 5-10 minutes, possibly stirring or gently shaking the container, until the tablet is dissolved, then can be passed through a feeding tube. This method involves dissolving tablets and capsules in warm water before suspending them for administration. This method could be used to administer Concor tablets through a feeding tube.
Const-K 750mg — The potassium content in fruits is relatively low, such as only about 2.2 mEq/inch or 0.9 mEq/cm in bananas. This means that consuming about two to three bananas is required to provide 40 mEq. Const-K is a type of extended-release tablet that contains 10 mEq/tab. One Const-K tablet provides less potassium than a single banana. If injectable potassium supplementation is not preferred, the tablet should be crushed into fine particles and taken with water.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
2023-12-08 - trastuzumab 6mg/kg 400mg NS 250mL 90min (maintenance dose)
2023-11-18 - trastuzumab 6mg/kg 400mg NS 250mL 90min (maintenance dose)
2023-10-23 - docetaxel 75mg/m2 120mg NS 250mL 1hr + trastuzumab 6mg/kg 400mg NS 250mL 90min (maintenance dose)
2023-10-02 - docetaxel 75mg/m2 120mg NS 250mL 1hr + trastuzumab 6mg/kg 395mg NS 250mL 90min (maintenance dose)
2023-09-08 - docetaxel 75mg/m2 120mg NS 250mL 1hr + trastuzumab 6mg/kg 389mg NS 250mL 90min (maintenance dose)
2023-08-18 - docetaxel 75mg/m2 120mg NS 250mL 1hr + trastuzumab 8mg/kg 514mg NS 250mL 90min (loading dose)
2023-07-28 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
2023-06-30 - liposome doxorubicin 30mg/m2 49mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 986mg NS 500mL 1hr
2023-06-09 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 990mg NS 500mL 1hr
2023-05-19 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
This patient has received six doses of Ogivri (trastuzumab) on the following dates: 2023-12-08, 2023-11-18, 2023-10-23, 2023-10-02, 2023-09-08, and 2023-08-18. The initial four doses were administered in combination with docetaxel. The patient reported skin symptoms approximately two weeks after the fifth dose of trastuzumab (2023-11-18), suggesting a possible link to trastuzumab.
Trastuzumab is known to potentially cause dermatologic adverse reactions, including skin rash (4% to 18%), acne vulgaris (2%), nail disease (2%), and pruritus (2%).
The discharged medications include those recommended by our dermatologist; it is advised to continue monitoring for changes in symptoms.
[glutathione - peripheral neuropathy]
Additionally, the pre-chemotherapy medications on 2023-10-02 and 2023-10-23 included glutathione. The 2020 ASCO systematic review of neuroprotectants for prevention of chemotherapy-induced peripheral neuropathy (CIPN) concluded that glutathione should not be offered for prevention of CIPN to patients receiving treatment with paclitaxel plus carboplatin, and that N-acetyl cysteine should not be offered to patients receiving potentially neurotoxic chemotherapy [1]. This position was also taken in the 2020 joint ESMO/EONS/EANO guidelines [2].
[1] Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325. [2] Systemic anticancer therapy-induced peripheral and central neurotoxicity: ESMO-EONS-EANO Clinical Practice Guidelines for diagnosis, prevention, treatment and follow-up. Ann Oncol 2020; 31:1306.
[diarrhea]
Both docetaxel and trustuzumab have been reported to be associated with diarrhea (23% to 43% and severe diarrhea <= 6% for the former and 7% to 25% for the latter).
In the event of diarrhea, it is recommended that loperamide (2 mg/cap) be used with an initial 2# followed by 1# every 2 to 4 hours or after each loose stool; for diarrhea persisting > 24 hours, administer 1# every 2 hours (or 2# every 4 hours). Continue until 12 hours have passed without loose stools. Doses > 8# per day may not provide benefit; consider alternative therapy if diarrhea persists >= 48 hours.
[leukopenia]
2023-10-02 WBC 6.23 x10^3/uL 2023-09-14 WBC 1.56 x10^3/uL 2023-09-08 WBC 6.62 x10^3/uL 2023-09-01 WBC 14.67 x10^3/uL 2023-08-25 WBC 1.67 x10^3/uL 2023-08-18 WBC 5.34 x10^3/uL 2023-07-28 WBC 7.35 x10^3/uL 2023-06-30 WBC 6.00 x10^3/uL 2023-06-09 WBC 6.17 x10^3/uL 2023-05-26 WBC 7.59 x10^3/uL 2023-05-12 WBC 11.26 x10^3/uL 2023-04-18 WBC 8.85 x10^3/uL
Leukopenia was observed on 2023-09-14 and 2023-08-25, approximately 1 week after the administration of docetaxel + trastuzumab (on 2023-09-08 and 2023-08-18), prophylactic G-CSF might be considered.
[G-CSF administration timing]
G-CSF is usually started no earlier than 24 hours after administration of chemotherapy. Continuation until the absolute neutrophil count following the nadir exceeds 10,000/microL, as specified in the G-CSF package insert, is known to be safe and effective. However, a shorter duration that is sufficient to achieve clinically adequate neutrophil recovery is a reasonable alternative, considering issues of patient convenience and cost. G-CSF should not be given in the day or days prior to the next cycle of chemotherapy, or on the same day as chemotherapy or radiation therapy is administered. Ref:
[exam findings]
[chemotherapy]
2023-09-28 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2
2023-09-07 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)
2023-08-31 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2
2023-08-11 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)
2023-08-04 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2
2023-07-14 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)
2023-07-10 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2
2023-06-23 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)
2023-06-16 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2
2023-05-29 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)
2023-05-22 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2
2023-04-19 - [liposome doxorubicin 30mg/m2 50mg D5W 100mL + carboplatin AUC 5 675mg NS 250mL] 90min IP (HIPEC)
2022-07-25 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
2022-07-01 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
2022-06-10 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
2022-05-17 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
2022-04-21 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
2022-03-31 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
2022-03-11 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
2022-02-16 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
2022-01-26 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
2022-01-05 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
2021-12-15 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
2021-11-24 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
2021-10-04 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
2021-09-10 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr
2021-08-18 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr
2021-07-29 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr
2021-07-02 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr
2021-05-31 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr
2021-04-27 - docetaxel 60mg/m2 95mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr
2021-03-23 - [liposome doxorubicin 30mg/m2 40mg D5W 100mL + carboplatin AUC 5 600mg NS 250mL] 90min IP (LipoDox dose reduced)
2020-01-14 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
Leukopenia was observed in mid-Sep with a nadir of 1.31K/uL, occurring after the administration of paclitaxel + cisplatin through IV on 2023-08-31, and paclitaxel through IP on 2023-09-07. Granocyte (lenograstim 250ug) has been administered for 3 consecutive days beginning on 2023-09-14, and no instances of leukopenia have been reported thus far.
2023-09-28 WBC 4.17 x10^3/uL
2023-09-21 WBC 7.00 x10^3/uL
2023-09-14 WBC 1.31 x10^3/uL ** 2023-09-10 WBC 1.96 x10^3/uL *
2023-09-07 WBC 3.70 x10^3/uL
According to data from both PharmaCloud and HIS5, the patient has only been treated in the hemato-oncology department at our facility. Consequently, no issues with medication reconciliation have been found.
Based on the records from the PharmaCloud and HIS5, the patient exclusively utilizes healthcare services at the hemato-oncology department in our hospital. As a result, no medication reconciliation discrepancies have been detected.
According to the PharmaCloud database, the patient only receives medical services from our hospital. Therefore, there are no identified medication reconciliation issues.
The PharmaCloud database reveals that all medical needs of this patient have been met at our hospital in the last three months. Consequently, no medication reconciliation issues have been identified.
The patient’s serum potassium level was slightly low at 3.3mmol/L as of 2023-06-16, and it has been trending downwards. It might be helpful to recommend that the patient consume more potassium-rich foods.
[MedRec]
[chemotherapy]
VTd regimen
[tube feeding]
The potassium content of fruits is relatively low (for example, about 2.2 mEq/inch or 0.9 mEq/cm in bananas), meaning that it would take about two to three bananas to provide 40 mEq. Const-K is an extended-release formulation containing 10 mEq/tab, which is less potassium than is found in one banana. If injectable potassium supplementation is not preferred, please crush the tablet into particles and administer it with water.
[diarrhea]
2023-09-02 Lab showed triglycerides (TG) 394 mg/dL and LDL-C 168mg/dL, Atozet (ezetimibe, atorvastatin) was initiated by our nephrologist. Due to recent diarrhea, Atozet is discontinued today. However, the possibility that Velcade (bortezomib) in VTd regimen (2023-05-26 started) may also be associated with diarrhea cannot be completely excluded.
By the way, a statin can be administered as an alternate day frequency with a similar efficacy and may have a lower incidence of side effects. Ref: Efficacy and Safety of Alternate-Day Versus Daily Dosing of Statins: a Systematic Review and Meta-Analysis. Cardiovasc Drugs Ther. 2017 Aug;31(4):419-431. doi: 10.1007/s10557-017-6743-0. PMID: 28741244.
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
{why 2023-07-25 exemestane shifted to letrozole?}
[MedRec]
According to the PharmaCloud database, this patient just refilled a 28-day supply of Switane (trihexyphenidyl), Ativan (lorazepam), Winsumin (chlorpromazine), and Denosin (desloratadine) for her schizophrenia at the Bali Psychiatric Center of the Ministry of Health and Welfare on 2023-09-13. Except for lorazepam, all other medications are currently in use. If agitation, restlessness, or antipsychotic-induced akathisia continues to be observed, reintroduction of lorazepam may be considered.
[exam findings]
[MedRec]
The patient refilled the repeat prescription for Norvasc (amlodipine), Tulip (atorvastatin), Ankomin (metformin), and Ozempic Injection (semaglutide) on 2023-09-09. However, she is not currently taking these drugs. It is recommended that her serum glucose and blood pressure levels be monitored to determine if and when these medications should be reintroduced.
[diagnosis] - 2023-03-15 admission note
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemoimmunotherapy]
The drugs prescribed by our endocrinologist have been added to the active medication list with no discrepancies found.
A 28-day supply of Ulstop (famotidine), Bokey (aspirin), Saline (nicametate), and Vemlidy (tenofovir alafenamide) are refilled on 2023-08-05, all added to the active formulary with no reconciliation issues found.
Our neurologist prescribed Ulstop (famotidine), Bokey (aspirin), Saline (nicametate citrate) on 2023-07-17, our ophthalmologist prescribed Xalatan (latanoprost), Azarga (brinzolamide, timolol), Alphagan (brimonidine) eye drops on 2023-07-31. These drugs are included in the active medication list without a reconciliation issue.
[reconciliation]
The prescription of Alphagan (brimonidine tartrate), Azarga (brinzolamide), and Xalatan (latanoprost) eye drops were refilled at a local pharmacy on 2023-06-26, with a valid 28-day duration for his glaucoma diagnosis. However, these drugs are not currently included in the patient’s active medication list. Please check whether these medications are still required for the patient.
U-Vanco (vancomycin) was changed from 1000mg Q12H to 1500mg Q12H on 2023-09-24 because the trough was 4.9mg/dL on that day. Since the updated trough level is even lower today (2023-09-28) at 4.3mg/dL, it is recommended that the dose be increased to 2000mg Q12H (Cre 0.32mg/dL, eGFR 377).
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[reconciliation]
The patient consistently refills his repeat prescription from LuoDong BoAi Hospital for Bokey (aspirin), Sevikar (amlodipine, olmesartan), and Livalo (pitavastatin). These drugs are currently being used with no discrepancies identified.
[dermatologic adverse reactions (5-FU)]
HIS5 records indicate that the patient visited our dermatologist on 2023-09-12 for suspected chemotherapy-related dermatopathy.
It has been reported that fluorouracil (administered initially on 2023-08-26 at a dose of 1800mg for 3 days) is associated with various dermatologic side effects, including alopecia, nail changes (including nail loss), dermatitis, hyperpigmentation (around veins), maculopapular rash (pruritic), palmar-plantar erythrodysesthesia, skin fissures, skin photosensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis, and xeroderma. Since the second dose was administered on 2023-09-27 at a lower dose of 1500mg for 3 days, it is advisable to monitor the patient closely for any recurrence of dermatopathy.
[exam findings]
This patient has been consistently taking cyclin-dependent kinase inhibitor Verzenio (abemaciclib 150mg) 1# BIDCC and aromatase inhibitor Femara (letrozole 2.5mg) 1# QD for months.
Dyspnea, with a frequency ranging from 6% to 18%, has been associated with the use of letrozole. Abemaciclib, on the other hand, has been linked to interstitial lung disease (ILD) and/or pneumonitis, with the frequency not yet defined.
In the event that ILD is confirmed, the abemaciclib dosage should be adjusted as follows:
Grade 1 or 2: No abemaciclib dosage modification is required.
Persistent or recurrent grade 2 toxicity that does not resolve to baseline or grade 1 within 7 days (despite maximal supportive measures): Withhold abemaciclib until toxicity resolves to baseline or to ≤ grade 1 and then resume abemaciclib at the next lower dose.
Grade 3 or 4: Discontinue abemaciclib.
[MedRec]
[surgical operation]
[immunochemotherapy]
2023-09-26 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
2023-09-06 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
2023-08-17 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
2023-07-31 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
2023-06-26 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
2023-06-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
2023-05-26 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
2023-05-11 - bevacizumab 5mg/kg 200mg NS 100mL 1.5hr
2023-05-09 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 500mL 45hr
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[anemia]
The last dose of FAC regimen was administered on 2023-09-01 and blood transfusion was performed on the same day, after almost 4 weeks on 2023-09-25 HGB was still below 7g/dL. The recovery of hematopoietic capacity may not be able to catch up, if anemia becomes symptomatic or considered severe, additional blood transfusion might be needed.
2023-09-25 HGB 6.4 g/dL
2023-09-22 HGB 6.8 g/dL
2023-09-01 HGB 6.0 g/dL
[oral mucositis]
For oral mucositis, ASCO recommends using normal saline or salt and soda rinses, 2% viscous lidocaine swish and spit, modifying the diet, using 2% morphine mouthwash swish and spit, and administering systemic opiates based on increasing symptom burden. Ref: Management of Cancer Therapy-Associated Oral Mucositis. JCO Oncol Pract. 2020;16(3):103-109. doi:10.1200/JOP.19.00652
The patient may benefit from using Nincort Oral Gel (triamcinolone acetonide) as a means of relieving symptoms. Additionally, Comfflam Anti-inflammatory Spray (benzydamine 1.5 mg/mL) is available at this hospital and can be used as a rinse three to four times daily (depending on the severity of the mucositis).
[anemia]
[anemia]
[restaging]
On 2023-05-31, a bone scan indicated the need for further monitoring of an active spot in the mid-T spine and heightened activity in the L2-4 spines to ascertain potential bone metastasis. Furthermore, an abdominal sonography on 2023-07-21 showed a slight presence of ascites. If the disease is ultimately confirmed to have metastasized, restaging may be necessary.
[anemia]
Recent HGB lab results
This patient received two cycles of FAC (5FU + LipoDox + Endoxan) on 2023-06-27 and 2023-07-20. Prior to treatment, the hemoglobin (HGB) level remained above 8 g/dL, but after the first cycle, the level decreased to 7.2 g/dL and further decreased to 6.8 g/dL on the day of the second cycle administration.
Pegylated liposomal doxorubicin is known to be associated with anemia (grade 3: 5%, grade 4: <1%), and anemia is also common in patients receiving cyclophosphamide and/or fluorouracil.
As the patient has end-stage renal disease (ESRD) with impaired hematopoietic function, appropriate administration of epoetin alfa is required in addition to iron supplementation. In emergency situations or as needed, blood transfusion should still be considered to maintain hemoglobin levels.
[MedRec]
[chemotherapy]
[MedRec]
Mesyrel (trazodone) is the only oral medication on the list of active medications that can be fed by tube.
[lab data]
2023-06-27 Anti-HBc Reactive
2023-06-27 Anti-HBc-Value 1.04 S/CO
2023-06-27 Anti-HCV Nonreactive
2023-06-27 Anti-HCV Value 0.10 S/CO
2023-06-27 Anti-HBs 229.48 mIU/mL
2023-06-27 HBsAg Nonreactive
2023-06-27 HBsAg (Value) 0.32 S/CO
[exam findings]
[MedRec]
[consultation]
[immunochemotherapy]
The lab data indicate an elevated TSH, decreased T3, normal T4, and normal Thyroglobulin levels. This could potentially suggest a subclinical hypothyroidism. It’s noted that there are no records of hypothyroidism in this patient’s history in HIS5. Is there a connection to GS-1811?
2023-09-15 TSH (NM) 9.395 uIU/ml 2023-09-15 Free T4 (NM) 1.165 ng/dl 2023-09-15 T3 (NM) 66.083 ng/dl 2023-09-15 Thyroglobulin 0.322 ng/ml
2023-08-24 TSH (NM) 25.789 uIU/ml 2023-08-24 Free T4 (NM) 1.337 ng/dl 2023-08-24 T3 (NM) 87.021 ng/dl 2023-08-24 Thyroglobulin <0.3 ng/ml
[prophylactic antiviral therapy prior to immunosuppressive agent use]
The patient’s hepatitis B serology results were as follows: HBsAg (-), anti-HBc (+), anti-HBs (+), indicating that she is immune due to natural infection but remains at risk for reactivation if exposed to immunosuppressive agents.
Given this information, if immunosuppressive agents are part of the treatment plan, it is recommended that prophylactic antiviral therapy be considered. Options include either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD. This preventive measure can help reduce the risk of possible reactivation of HBV infection due to the immunosuppressive effects of treatment.
{triple negative breast cancer}
[exam findings]
[MedRec]
[chemotherapy]
docetaxel 75mg/m2 and carboplatin AUC 6, cycled every 21 days x 4-6 cycles, preoperative setting only - NCCN 2022-06-21
[note]
PREOPERATIVE/ADJUVANT THERAPY REGIMENS - HER2-Negativeb (Breast Cancer NCCN Guidelines 20220621 Version 4.2022, BINV-L 1 OF 9, p55)
According to PharmaCloud records, the patient has only been seen at our hospital for the past three months. After reviewing the HIS5 records, no medication reconciliation issues were identified.
[Trodelvy (sacituzumab govitecan)]
Trodelvy (sacituzumab govitecan) has received approval from the TFDA and is prescribed for two specific indications:
However, it’s important to note that this medication is not currently covered by the NHI program. Therefore, it may pose a financial burden for patients who are economically disadvantaged.
[exam findings]
[MedRec]
[chemotherapy]
[renal dose for carboplatin, metoclopramide and cimetidine]
2023-07-04 Cre 1.56mg/dL, eGFR 46.6, weight 75.9kg => CrCl 45mL/min. The patient has kidney impairment, which might necessitate dose adjustments for some medications in the active list:
Please review the dosages and clinical conditions accordingly to ensure safe and effective therapy for the patient.
[exam findings]
According to the PharmaCloud database, this patient has received Glivec (imatinib) prescribed at Cardinal Tien Hospital for at least the last 3 months. BCR-ABL tyrosine kinase inhibitors, such as imatinib, dasatinib, nilotinib, bosutinib, ponatinib, and asciminib, have been associated with varying degrees of cardiovascular adverse reactions. Taking imatinib as an example, its incidence includes chest pain (7% to 11%), edema (11% to 86%; severe edema: 2% to 11%), peripheral edema (20% to 41%), cold extremity (≤1%), flushing, heart failure (≤1%), hypertension (4%), hypotension (≤1%), palpitations (5%), pericardial effusion (≤6%), Raynaud’s disease (≤1%), subdural hematoma (≤1%), syncope (≤1%), tachycardia (≤1%), and <1%: acute myocardial infarction, angina pectoris, atrial fibrillation, cardiac arrhythmia, left ventricular dysfunction (ref: UpToDate). The discontinuation of the drug is considered to be appropriate in this case (LVEF 24%).
Imatinib has been associated with various cardiovascular side effects, including: chest pain (7% to 11%), edema (11% to 86%; severe edema: 2% to 11%), peripheral edema (20% to 41%), cold extremity (≤1%), flushing, heart failure (≤1%), hypertension (4%), hypotension (≤1%), palpitations (5%), pericardial effusion (≤6%), Raynaud’s disease (≤1%), subdural hematoma (≤1%), syncope (≤1%), tachycardia (≤1%) and <1%: acute myocardial infarction, angina pectoris, atrial fibrillation, cardiac arrhythmia, left ventricular dysfunction.
It’s important to note that other drugs in the same class as imatinib may also have cardiovascular adverse reactions.
Dasatinib: >10%: peripheral edema, cardiac conduction disturbance (7%; including cardiac arrhythmias [tachycardia, ventricular arrhythmia, ventricular tachycardia] and palpitations), cardiac disorder (≤4%; including cardiomyopathy, heart failure, left ventricular dysfunction, ischemic heart disease, reduced ejection fraction), chest pain, edema (1% to 4%), flushing, hypertension, pericardial effusion (1% to 4%), prolonged QT interval on ECG (≤1%) and <1%: Abnormal T waves on ECG, acute coronary syndrome, angina pectoris, cardiomegaly, coronary artery disease, deep vein thrombosis, embolism, hypotension, livedo reticularis, myocarditis, pericarditis, pleuropericarditis, prolongation P-R interval on ECG, pulmonary embolism, syncope, thrombophlebitis, thrombosis, troponin increased in blood specimen.
Nilotinib: hypertension (10% to 11%), occlusive arterial disease (9% to 15%; including limb stenosis), peripheral edema (9% to 15%), prolonged QT interval on ECG (children and adolescents: >30 msec from baseline: 28%; adults: >60 msec from baseline: 4%; adults: >500 msec: <1%), angina pectoris, cardiac arrhythmia (including AV block, atrial fibrillation, bradycardia, cardiac flutter, extrasystoles, and tachycardia), cerebral ischemia (1% to 3%), chest discomfort, chest pain, flushing, ischemic heart disease (5% to 9%), palpitations, pericardial effusion (≤2%), peripheral arterial disease (3% to 4%) and <1%: Acute myocardial infarction, arteriosclerosis, cardiac failure, cerebral infarction, coronary artery disease, coronary artery disease, facial edema, heart murmur, hypertensive crisis, intermittent claudication, ischemic stroke, syncope, transient ischemic attacks.
Bosutinib: chest pain (8% to 12%), edema (15% to 19%), hypertension (8% to 11%), coronary artery disease (3%), heart failure (2% to 5%), pericardial effusion, prolonged QT interval on ECG and <1%: Pericarditis.
Ponatinib: cardiac arrhythmia (17% to 25%; ventricular arrhythmia: 3%), edema (≤41%), heart failure (6% to 16%), hypertension (31% to 53%; severe hypertension: 3% to 13%), occlusive arterial disease (13% to 31%; including carotid, vertebral, and middle cerebral artery and renal artery stenosis), peripheral edema (17%), acute myocardial infarction (2%), atrial fibrillation (8%), bradycardia (≤1%; including leading to pacemaker implantation), cerebral infarction (grade 3/4: 2%), cerebrovascular occlusion (7%), coronary artery disease (grade 3/4: 2%), deep vein thrombosis (2%), pericardial effusion (4%), peripheral arterial disease (occlusive: grades 3/4: 3%), pulmonary embolism (2%), reduced ejection fraction (3%), syncope (2%), venous thromboembolism (4% to 10%) and <1%: atrial flutter, atrial tachycardia, complete atrioventricular block, hypertensive crisis, prolonged QT interval on ECG, retinal thrombosis, sinus bradycardia, sinus node dysfunction, subdural hematoma, superficial thrombophlebitis, supraventricular tachycardia, tachycardia, ventricular tachycardia.
Asciminib: hypertension (14%), increased serum creatine kinase (30%), cardiac arrhythmia (<10%), edema (<10%), heart failure (<10%), palpitations (<10%), prolonged QT interval on ECG (<10%)
[diagnosis] - 2023-03-27 discharge note
[past history]
[allergy]
[family history]
[exam findings]
2023-04-23 CXR
2023-04-18 SONO - abdomen
2023-04-13 CXR
2023-04-11 CXR
2023-03-24, -03-17 CXR
2023-03-21 CT - abdomen
2023-03-17 KUB
2023-03-15, -03-12 CXR
2023-02-12 ECG
2023-01-09 Nasopharyngoscopy
2022-12-28 Cholangiography
2022-12-28 Endoscopic Retrograde CholangioPancreatography, ERCP
2022-12-26 Percutaneous Transhepatic Cholangio-Drainage, PTCD
2022-12-23 Patho - gallbladder (benign lesion)
2022-12-12 Percutaneous Transhepatic Cholangio-Drainage, PTCD
2022-12-12 SONO - abdomen
2022-12-11, -11-08 CXR
2022-11-11 2D transthoracic echocardiography
2022-11-22 Flow volume chart
2022-11-21 SONO - abdomen
2022-11-17 CT - abdomen
2022-11-12 MRI - MR Cholangiography, MRCP
2022-11-11 Patho - liver biopsy needle/wedge
2022-11-10 Endoscopic Retrograde CholangioPancreatography, ERCP
2022-11-09 CT - abdomen
2021-04-13 Bone densitometry - hip
[MedRec]
[consultation]
[surgical operation]
[MedRec]
[radiotherapy]
[chemotherapy]
2023-05-17 ~ undergoing - UFT (tegafur 100mg, uracil 224mg) 1# BID
2023-02-06 - fluorouracil 200mg/m2 300mg NS 500mL 24hr D1-5
2023-02-02 - fluorouracil 200mg/m2 300mg NS 500mL 24hr D1-2
[note]
Principles of Systemic Therapy — NCCN Clinical Practice Guidelines in Oncology - Biliary Tract Cancers - Version 2.2023 - May 10, 2023 - BIL-C
Principles of Systemic Therapy — NCCN Clinical Practice Guidelines in Oncology - Hepatocellular Carcinoma - Version 1.2023 - March 10, 2023 - HCC-G
According to the PharmaCloud data, this patient has only sought medical care at our hospital in the past three months. No discrepancies or problems were identified during the medication reconciliation process for this patient.
The patient’s treatment was changed to UFT (a combination of Tegafur and Uracil) on 2023-05-17. There is limited data on the tolerability of UFT in older adults. However, in a study with a control group of 39 patients over 70 years of age who had undergone resection for colorectal cancer and received UFT alone, adverse events were rare and all were grade 2 or less (Reference: Cancer Biother Radiopharm. 2009;24(1):35-40). Given the patient’s advanced age, the chosen drug appears to be appropriate.
The drug UFT is approved in Taiwan and other countries, but is not approved by the FDA, Health Canada, or the European Medicines Agency (EMA), and is therefore not recommended by the NCCN guidelines. UFT consists of a 1:4 molar combination of tegafur (a prodrug of 5-FU) and uracil (which competitively inhibits the degradation of 5-FU, resulting in sustained plasma and intratumoral concentrations). As tegafur is a prodrug of 5-FU, which has already been used in this patient in concurrent chemoradiotherapy (CCRT), the efficacy of this approach should be continuously monitored as always.
Amsulber (ampicillin, sulbactam) is used due to 2023-04-13 CRP 2.1mg/dL and CXR showed ground glass opacities in bilateral lower lungs.
Baogan (silymarin) is being used for the patient’s elevated AST and ALT.
[MedRec]
Some of the medications prescribed by our gastroenterologist on 2023-07-28 and by our endocrinologist on 2023-07-18 do not appear in the active medication list. Please verify if these omitted medications are still necessary for the patient’s treatment.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[oral mucositis]
Since 2023-06-13, the patient has been intermittently receiving radiotherapy. Regarding chemotherapy, after the last TPFL (docetaxel + cisplatin + 5-FU + LV) treatment on 2023-06-13, the patient transitioned to cisplatin + methotrexate starting from 2023-08-21. While oral mucositis could potentially be caused by chemotherapy, it’s important to note that the influence of radiotherapy cannot be entirely ruled out.
According to the recommendations in the article “Management of Cancer Therapy-Associated Oral Mucositis” (https://ascopubs.org/doi/full/10.1200/JOP.19.00652), management options for mucositis severity include bland rinses (normal saline or salt and soda), 2% viscous lidocaine swish and spit, gabapentin, 2% morphine mouthwash swish and spit, doxepin-containing mouthwashes, and systemic opiates, depending on the severity of mucositis.
[lab data]
2022-09-09 Anti-HBc Reactive
2022-09-09 Anti-HBc-Value 2.22 S/CO
2022-09-09 Anti-HBs 81.03 mIU/mL
2022-09-09 HBsAg (quantative) Nonreactive
2022-09-09 HBsAg Value (quantative) 0.00 IU/mL
2022-09-09 Anti-HCV Nonreactive
2022-09-09 Anti-HCV Value 0.11 S/CO
[exam finding]
[consultation]
[chemoimmunotherapy]
[renal function follow-up]
Given the recent serum Cre and BUN records, it appears that the patient’s AKI status has been resolved for some time. Therefore, this might be marked as an inactive or resolved item in the medical problem list.
[diagnosis] - 2023-03-20 admission note
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
High-grade neuroendocrine carcinomas (NEC) with poor differentiation tend to have a high likelihood of developing distant metastases and a concerning prognosis, even when they appear to be clinically localized. For the treatment of metastatic gastrointestinal and pancreatic NEC, it is often recommended to use a two-drug platinum-based regimen, usually consisting of cisplatin or carboplatin combined with etoposide.
The ideal treatment duration remains undetermined. Generally, the goal is to administer 4 to 6 cycles of therapy. However, if a patient continues to respond positively to the treatment and experiences minimal side effects, it may be suitable to extend chemotherapy until the maximum possible response is achieved. ref: UpToDate. https://www.uptodate.com/contents/high-grade-gastroenteropancreatic-neuroendocrine-neoplasms
Neuroendocrine tumors, metastatic carcinoma
The patient’s current etoposide and cisplatin regimen does not exceed the mentioned dosage, making it suitable and not necessitating any dosage adjustments.
[MedRec]
[surgical operation]
[chemotherapy]
[diarrhea]
The patient started FOLFIRI treatment on 2023-08-22 and experienced significant diarrhea, with seven or more bowel movements per day.
Irinotecan, a component of FOLFIRI, can lead to both early and late-stage diarrhea. For early-stage diarrhea, which may come with cholinergic symptoms, atropine can be effective. Although a 0.25mg dose of atropine was initially used, increasing the dose to 0.5mg during the next treatment could be considered (can be up to 1mg). Late-stage diarrhea requires immediate attention with loperamide, as it could be life-threatening.
In cases of diarrhea, maintain close monitoring of fluid and electrolyte levels, and provide necessary supplementation. If complications like ileus, fever, or severe neutropenia arise, antibiotics may be needed. In the event of severe diarrhea, consider interrupting the irinotecan treatment and adjusting the dosage for subsequent administrations.
Patients who are homozygous for the UGT1A128 or 6 alleles (28/28, 6/6), or compound heterozygous UGT1A128 and 6 alleles (6/28), may require a dose reduction in the starting irinotecan level. Any future adjustments should be tailored to individual tolerance levels.
For treating diarrhea induced by cancer therapy, the initial oral dose of loperamide is 4 mg, followed by 2 mg every 2 to 4 hours or after each instance of loose stool. If diarrhea continues for more than 24 hours, the dose should be 2 mg every 2 hours, or alternatively, 4 mg every 4 hours. Continue this regimen until 12 hours have elapsed without a loose bowel movement, as per guidelines from Andreyev 2014, Benson 2004, and Sharma 2005. It’s worth noting that daily doses exceeding 16 mg may not offer additional benefit, and alternative treatments should be considered if diarrhea persists for 48 hours or more.
[leukopenia]
Around the third week following the patient’s initial FOLFIRI treatment, leukopenia was detected. However, after administering a dose of G-CSF (filgrastim 150ug) on 2023-09-11, no further instances of leukopenia have been observed as of now.
2023-09-12 WBC 4.70 x10^3/uL
2023-09-11 WBC 1.58 x10^3/uL
2023-09-08 WBC 1.81 x10^3/uL
2023-09-05 WBC 1.95 x10^3/uL
2023-08-22 WBC 4.85 x10^3/uL
[exam findings]
[MedRec]
[chemotherapy]
2023-09-11 FOLFOX
2023-08-16 FOLFOX
2023-07-28 FOLFOX
2023-07-12 FOLFOX
2023-06-26 FOLFOX
2023-06-05 FOLFOX
2023-05-08 FOLFOX
2023-04-10 FOLFOX
2023-03-21 FOLFOX
2023-03-03 FOLFOX
2023-02-16 FOLFOX
2023-01-16 5-FU
2023-01-09 5-FU
2022-12-30 5-FU
2022-12-28 5-FU
The medications in the repeat prescription provided by VGHTPE on 2023-08-09 were replenished on 2023-09-04 and are currently in use. No issues with medication reconciliation have been identified.
This patient obtained a 28-day refill of aspirin, bisoprolol, fenofibrate, ezetimibe, amlodipine, and atorvastatin from VGHTPE on 2023-08-09. All these medications are actively being used, and there are no discrepancies identified.
This patient refilled a prescription on 2023-07-03 that was issued by VGHTPE on 2023-05-10 for aspirin, bisoprolol, fenofibrate, ezetimibe, amlodipine and atorvastatin. These drugs are now on the active formulary with no reconciliation issues identified.
[exam findings]
[MedRec]
[consultation]
[chemoimmunotherapy]
According to PharmaCloud, this patient has no records of visiting other healthcare facilities in the past three months. The repeat prescriptions for Baraclude (entecavir) and Harnalidge (tamsulosin), issued on 2023-08-10 by our hospital OPD, are currently on the active medication list and no reconciliation issues have been identified.
[bedside visit]
[exam findings]
[MedRec]
[consultation]
2023/06/16 AST 237 ALT 441 ALP 430 GGT 1489 TBI 2.97 DBI 1.74; WBC 9.65 Seg 94.8% CRP 1.2 PCT 0.36
2023/06/23 AST 68 ALT 127 ALP 239 GGT 993 TBI 5.64 DBI 3.43 PT 11.5 NH3 51
2023/06/17 HBsAg-/AntiHBs+/AntiHCV-
2023/06/23 TSH 0.053 (low), T3 0.67 (low) FT4 1.27; cortisol 17.74
[treatment]
2023-07-07 ~ undergoing - Xtandi (enzalutamide 40mg) 4# QDAC
2023-07-10 - Zoladex Depot (goserelin 3.6mg) SC ST
2023-05-09 - Firmagon (degarelix 80mg) at Taipei Mackey Hospital
2023-04-11 - Firmagon (degarelix 80mg) at Taipei Mackey Hospital
2023-05-09 - Xgeva (denosumab)
2023-04-11 - Xgeva (denosumab)
[hyperbilirubinemia]
This patient’s blood bilirubin level has increased significantly since late August.
2023-09-04 Bilirubin total 25.09 mg/dL 2023-08-31 Bilirubin total 19.49 mg/dL 2023-08-29 Bilirubin total 19.02 mg/dL 2023-08-29 Bilirubin total 19.02 mg/dL 2023-08-28 Bilirubin total 18.30 mg/dL 2023-08-24 Bilirubin total 13.31 mg/dL 2023-08-21 Bilirubin total 10.81 mg/dL 2023-08-17 Bilirubin total 6.25 mg/dL 2023-08-14 Bilirubin total 3.61 mg/dL 2023-08-10 Bilirubin total 1.49 mg/dL 2023-08-08 Bilirubin total 1.03 mg/dL 2023-08-07 Bilirubin total 1.19 mg/dL
2023-09-04 Bilirubin direct 14.35 mg/dL 2023-08-31 Bilirubin direct 12.67 mg/dL 2023-08-29 Bilirubin direct 12.16 mg/dL 2023-08-29 Bilirubin direct 12.16 mg/dL 2023-08-28 Bilirubin direct 9.94 mg/dL 2023-08-24 Bilirubin direct 7.89 mg/dL 2023-08-21 Bilirubin direct 6.44 mg/dL 2023-08-17 Bilirubin direct 3.58 mg/dL 2023-08-14 Bilirubin direct 2.11 mg/dL 2023-08-10 Bilirubin direct 0.74 mg/dL 2023-08-08 Bilirubin direct 0.37 mg/dL
Upon reviewing all drugs on the active medication list, 3 drugs are found to be associated with liver-related adverse reactions:
[Brosym 1000mg Q12H for patients with CrCl < 15mL/min]
Patient: Male, 70 years old, weighing 52kg, with a creatinine level of 3.58mg/dL, resulting in a creatinine clearance (CrCl) of 14mL/min.
According to the Sanford Guide, the recommended maximum dose of sulbactam for patients with a CrCl < 15mL/min is 500mg every 12 hours. Therefore, the appropriate dose for this patient would be Brosym 1000mg every 12 hours.
[to increase the dose of long-acting insulin]
Considering that fasting blood glucose levels from 2023-07-10 to 2023-07-12 are still on the high side, ranging around 200mg/dL to 300mg/dL, even with the current insulin regimen of Apidra (insulin glulisine) 3 units TIDAC and Tresiba (insulin degludec) 6 units HS for days, it is recommended to increase the dosage of Tresiba from 6 units to 7 units and continue monitoring blood glucose levels to determine if further adjustments are necessary.
[bilirubin level follow-up]
The patient’s bilirubin levels have remained stable over the past two weeks.
Upon reviewing the drugs in the patient’s active medication list, there is no clear evidence suggesting a need to adjust the dosages based on the current state of the patient’s liver function.
[bedside visit]
I visited the patient around 09:15 on 2023-07-10. He was lying in bed with his eyes closed, and his wife and a caregiver were present in the room. The patient didn’t respond when I conversed with his wife and the caregiver.
The patient’s caregiver mentioned that the patient’s feet were cold, so she placed a warm water bag near his feet to try to provide warmth. The patient’s wife reported that the patient had begun to sweat profusely on his head the previous night (without night sweats from the body), had not slept all night, and had a poor appetite, eating only a small amount.
Upon asking about the patient’s pain, bowel movements, and breathing, the caregiver indicated that the patient’s stools were regular, but his urine output was reduced due to concerns about pulmonary edema and fluid retention leading to reduced fluid intake. The patient continues to experience occasional shortness of breath and expresses discomfort, but there has been no significant increase in the intensity or duration of pain.
[Zoladex (goserelin)]
There is no dosage adjustment necessary for Zoladex (goserelin) in kidney impairement and/or hepatic impairment patients.
NHI provides coverage for the use of Gn-RH analogs, such as goserelin, exclusively for conditions like prostate cancer, central precocious puberty, endometriosis, and breast cancer in pre-menopausal (or peri-menopausal) cases. This patient should meet the criteria for coverage.
[bedside visit: breathing smoother]
I visited the patient on 2023-07-06 at approximately 10:30. The patient was in bed, using an oxygen mask with his eyes closed, and his wife and daughter were in the room with him. I noticed that the patient’s breathing did not seem rapid. I asked his wife and daughter about the patient’s condition, and his daughter replied that the patient’s breathing seemed smoother than it had been in the past few days and that there were no specific problems at the moment. When I asked if they had any questions about the medication or wanted to understand more, they indicated that they did not have any at this time.
[patient education: enzalutamide]
The patient agreed to use Xtandi (enzalutamide). I prepared an information sheet about enzalutamide, highlighting points the patient should be aware of, as well as potential side effects of the medication. At approximately 14:10 on 2023-07-06, I visited the patient, who was resting in the room with his daughter and caregiver. I gently woke the patient’s daughter and gave her the highlighted sheet. I also gave her the contact information for the pharmacy window and encouraged her to call if she had any questions about the medication.
[Minutes of the Multidisciplinary Team Meeting and Patient Family Meeting]
Today, on 2023-06-30 at around 11:45, Dr. Hsia gathered the patient’s daughter and the patient’s wife’s brother, and explained the current status of the patient’s condition using medical images. Then, from 12:15 to 13:15, a multidisciplinary team meeting and family meeting was held in the ward conference room. The meeting was chaired by Dr. Hsia and included members such as the nurse practitioner, the head nurse of the ward, the charge nurse, the social worker, and myself as the pharmacist. The the patient’s family representatives included the patient’s daughter and the patient’s wife’s brother. Dr. Hsia first clarified several key observations and considerations about the patient’s current condition. I presented the rationale behind the selection of anti-androgen agents, taking into account the expected changes in liver function. In addition, each of the nursing professionals also expressed their own perspectives.
Going forward, the pharmacy will continue to collaborate with the entire team in the management of this patient.
[bedside visit]
I visited the patient around 13:15 on 2023-06-30. The patient was using an oxygen mask, and his wife was standing by his bed. I asked about the patient’s current condition, and his wife indicated that he still had difficulty breathing, but he no longer coughed up blood. Upon checking the patient’s feet, I did not find any signs of lower limb edema.
[Rationale for the Selection of Anti-Androgen Agents in Patients with Potential Hepatic Impairment]
We currently have three anti-androgen medications in stock: Casodex (bicalutamide 50mg), Xtandi (enzalutamide 40mg), and Nubeqa (darolutamide 300mg), with the last one is a temporary purchase item and thus limited its use for certain patients.
Considering the patient’s normal AST and ALT levels along with elevated bilirubin (direct 0.78mg/dL, total 1.71mg/dL) as of 2023-05-29, the patient’s liver function should be taken into account when prescribing these drugs.
In conclusion, enzalutamide appears to be least affected by liver function and could be a reasonable choice if the patient’s liver function is not expected to recover in the short term.
The PharmaCloud database does not disclose any data for this patient, which could be due to the patient not having granting access.
In the past 3 years, there have been no records of outpatient or inpatient services for this patient at our hospital prior to this hospitalization. Consequently, no medication reconciliation issues have been detected.
Since the patient’s admission, fasting blood glucose levels have consistently ranged between 200 and 300 mg/dL, even with the administration of regular insulin 2 units PRNQ6H. To better manage these elevated blood sugar levels, it is advisable to increase the insulin dose to 3 units just before each meal. This approach trys to prevent blood glucose levels from exceeding 200 mg/dL. Continue to monitor blood glucose readings to assess the effectiveness of this adjustment and determine if further changes are needed.
The fasting serum glucose levels since this hospitalization were between 200 and 300 mg/dL even under regular insulin 2 units PRNQ6H. It is recommended to increase the dose to 3 unit right before each prandial to keep the blood sugar level at least not exceed 200mg/dL and keep monitoring the readings to decide if furthur adjustment necessary.
[exam findings]
[MedRec]
[radiotherapy]
[chemotherapy]
After reviewing the PharmaCloud and HIS5 records, no issues with medication reconciliation were identified. However, a blood glucose level of 263mg/dL recorded at 06:21 on 2023-09-05 suggests that glucose control may be suboptimal despite the use of multiple antidiabetic medications. Continuous monitoring of blood sugar levels is recommended to identify any developing trends.
[hypertriglyceridemia > 1000mg/dL]
During the months of June and July, there was a significant increase in triglyceride levels, leading to severe hypertriglyceridemia (exceeding 1000 mg/dL). Elevated triglycerides could interfere with an initial stage of the insulin signaling pathway, or conversely, insulin resistance might be contributing to the hypertriglyceridemia.
2023-08-26 Triglyceride (TG) 2209 mg/dL
2023-08-19 Triglyceride (TG) 1581 mg/dL
2023-08-05 Triglyceride (TG) 1183 mg/dL
2023-07-29 Triglyceride (TG) 2254 mg/dL
2023-07-22 Triglyceride (TG) 1814 mg/dL
2023-07-13 Triglyceride (TG) 2383 mg/dL
2023-07-08 Triglyceride (TG) 1802 mg/dL
2023-06-03 Triglyceride (TG) 597 mg/dL
2023-05-06 Triglyceride (TG) 491 mg/dL
2023-04-08 Triglyceride (TG) 495 mg/dL
2023-03-11 Triglyceride (TG) 409 mg/dL
2023-02-11 Triglyceride (TG) 318 mg/dL
2023-01-14 Triglyceride (TG) 309 mg/dL
Hypothyroidism is most often associated with hypercholesterolemia (2023-07-08 cholestrol total 355 mg/dL), but association with hypertriglyceridemia has also been described. Ref: Thyroid function and prevalent and incident metabolic syndrome in older adults: the Health, Ageing and Body Composition Study. Clin Endocrinol (Oxf). 2012;76(6):911-918. doi:10.1111/j.1365-2265.2011.04328.x
When the TG level is >1000 mg/dL, drugs used to lower TG have limited effectiveness. These agents work primarily by reducing hepatic TG synthesis and secretion as VLDL-TG and thus are relatively ineffective when TG level is severely elevated.
[patient education]
At around 15:15 on 2023-06-20, I visited the patient, who was resting with her eyes closed. Her sister, who was sitting in a chair next to the bed, woke her up. I brought the patient information leaflets for paclitaxel and carboplatin, explaining the potential side effects of each drug one by one. I asked her to inform the medical team as soon as possible if any suspicious symptoms occur. The patient reported that she had previously told Dr. Wan about numbness in her fingertips after chemotherapy, and stated that this condition still persists at the time of this visit.
Although carboplatin has been linked to peripheral neuropathy in 4% to 6% of cases, the association is even stronger with paclitaxel, which is linked to peripheral neuropathy in 42% to 70% of cases (grades 3/4 <= 7%). Therefore, it’s more probable that the numbness in the patient’s fingertips is primarily due to paclitaxel.
The 2020 ASCO guidelines suggest that clinicians may consider offering duloxetine to patients with chemotherapy-induced peripheral neuropathy. Additionally, the 2020 joint ESMO/EONS/EANO guidelines recommend duloxetine for the treatment of neuropathic pain in this context. Reference: “Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325”.
We currently have Cymbalta (duloxetine 30mg/cap) in stock. For chemotherapy-induced peripheral neuropathy, the oral initial dose is 30 mg once daily for 1 week, then increased to 60 mg once daily. (ref: UpToDate)
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[reconciliation]
A refill for a 28-day quantity of Omeprotect (omeprazole) and Dulcolax (bisacodyl) was recently completed on 2023-08-05, but these medications are currently not listed in the active medication records. Kindly assess whether these drugs are no longer required for the patient.
[reconciliation]
On 2023-07-08, the patient just refilled a 28-day supply of Omeprotect (omeprazole) and Dulcolax (bisacodyl), and on 2023-07-10 refilled a 30-day supply of Anxoken (metformin), Kludone (gliclazide), and Forxiga (dapagliflozin). However, metformin is currently absent from the active medication list, and a serum glucose level of 341mg/dL was recorded on 2023-07-19 at 16:16. It is advisable to determine if the omission of metformin is deliberate or due to the scheduling of a CT scan.
[exam findings]
[consultation]
The patient monthly refills for his repeat prescription medications, which include famotidine, silymarin, vitamin B complex, and propranolol, with the last refill occurring on 2023-08-06. Please confirm whether these medications are no longer required for the patient’s current medical status.
[MedRec]
On 2023-08-05, the patient received a 30-day prescription for pioglitazone, linagliptin, pentoxifylline, amlodipine, irbesartan, and atorvastatin. Not all of these medications are currently on the list of active medications. Please check to see if any of these medications are no longer needed.
[exam findings]
[consultation]
[surgical operation]
[chemoimmunotherapy]
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
[vancomycin dosing for adults with normal kidney function]
Loading dose (for patients with known or suspected severe Staphylococcus aureus infection) 20 to 35 mg/kg (based on actual body weight, rounded to the nearest 250 mg increment; not to exceed 3000 mg). Within this range, we use a higher dose for critically ill patients; we use a lower dose for patients who are obese and/or are receiving vancomycin via continuous infusion. The patient’s weight is approximately 50 kg, which suggests a loading dose range of 1000mg to 1750mg. The administered dose of 1000mg on 2023-08-28 at 10:49 falls on the lower end of this range.
Initial maintenance dose and interval typically 15 to 20 mg/kg every 8 to 12 hours for most patients (based on actual body weight, rounded to the nearest 250 mg increment). The dosage of 20mg/kg every 12 hours is then being administered to this date currently.
Given the lower initial loading dose and the recently observed elevated trough level of 16.5 mg/L (2023-08-31 morning), a 20% reduction in the current dosage is recommended, which equates to administering 800mg Q12H.
[diagnosis] - 2023-04-06 admission note
[lab data]
2023-06-28 CMV IgM Nonreactive
2023-06-28 CMV IgM Value 0.04 Index
2023-06-28 FLT3/ITD Presence of mutation * 2023-06-28 NPM1
Undetectable
2023-06-28 PML-RARA 0.0000
2023-06-28 BCR／abl Undetectable
2023-06-28 CMV viral load assay Target not detecetedIU/mL
2023-04-22 CMV IgM Nonreactive
2023-04-22 CMV IgM Value 0.08 Index
2023-04-22 CMV_IgG Reactive
2023-04-22 CMV_IgG Value 49.0 AU/mL
2023-02-01 CMV viral load assay Target not detecetedIU/mL
2023-01-27 CMV_IgG Reactive
2023-01-27 CMV_IgG Value 22.8 AU/mL
2023-01-27 CMV IgM Nonreactive
2023-01-27 CMV IgM Value 0.12 Index
2023-01-20 BM chromosome analyz
- CYTOGENETICS LABORATORY REPORT - Chromosome Analysis： - Tissue
Examined：Bone marrow - Staining Method：G-Banding - Colony number：NA -
Bands level：350 - Chromosome Counts： - 45-()、46-(20)、47-()、Other-()
Total-(20) - Karyotype：46,XY[20] - Interpretation： - Analysis of this
bone marrow sample shows a male having 46,XY[20] karyotype. No
chromosomal abnormality was detected. - Note： - ROUTINE BANDED LEVEL
DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF
RESOLUTIONS.
2023-01-17 FLT3-D835 Undetectable
2023-01-12 PML-RARA Presence of mutation *
2023-01-12 BCR/abl Undetectable
2023-01-12 FLT3/ITD Presence of mutation * 2023-01-12 NPM1
Undetectable
2023-01-10 CMV IgM Nonreactive
2023-01-10 CMV IgM Value 0.21 Index
2023-01-10 CMV_IgG Reactive
2023-01-10 CMV_IgG Value 11.8 AU/mL
2023-01-10 Anti-HBc Nonreactive
2023-01-10 Anti-HBc-Value 0.70 S/CO
2023-01-10 HBsAg Nonreactive
2023-01-10 HBsAg (Value) 0.33 S/CO
2023-01-10 Anti-HCV Nonreactive
2023-01-10 Anti-HCV Value 0.13 S/CO
[exam findings]
[consultation]
[chemotherapy]
Granocyte (lenograstim 250ug) CGRAN01
G-CSF (filgrastim 150ug) CGCSF01
2023-01-13 - tretinoin 50mg
[note]
Rydapt (midostaurin) https://www.uptodate.com/contents/midostaurin-drug-information
Chemotherapy regimens for relapsed or refractory acute myeloid leukemia (AML) in adults — 2023-07-04 - https://www.uptodate.com/contents/image?imageKey=HEME%2F82823
Cytarabine — 2023-04-12 - https://www.uptodate.com/contents/cytarabine-conventional-drug-information
FLAG-IDA for acute myeloid leukemia — 2023-07-04 - https://aml-hub.com/medical-information/flag-ida-for-acute-myeloid-leukemia
FLAG-Ida for Acute Myeloid Leukaemia (AML) — 2023-07-04 - https://media.leukaemiacare.org.uk/wp-content/uploads/FLAG-Ida-for-Acute-Myeloid-Leukaemia-AML-Web-Version.pdf
FLAG (fludarabine + high-dose cytarabine + G-CSF): an effective and tolerable protocol for the treatment of ‘poor risk’ acute myeloid leukemias — https://pubmed.ncbi.nlm.nih.gov/7526088/
[Posanol (posaconazole) initial dose may be insufficient]
For prophylactic treatment against invasive fungal infections, the package insert recommends administering Posanol (posaconazole) at a dose of 300 mg twice on the first day, followed by 300 mg daily thereafter.
Failing to administer the medication twice on the initial day could potentially compromise or delay its intended effects.
[pancytopenia]
Rydapt (midostaurin 25 mg) 2# PO Q12H has been initiated since 2023-07-28. The package insert recommends taking the medication with food. Please ensure that the patient takes the medication with food Q12H.
The following adverse drug reactions and incidences are associated with midostaurin:
Since pancytopenia had already developed before this drug administration, it would be difficult to distinguish to what extent the subsequent pancytopenia would gradually be attributed to midostaurin (if any).
[pancytopenia]
Both fludarabine and cytarabine, which are components of the FLAG regimen, are known to cause bone marrow suppression, especially fludarabine.
The patient received two cycles of the FLAG regimen, one on 2023-06-21 and the other on 2023-07-19. The first cycle resulted in a 5-day period (2023-06-28 to 2023-07-02) of WBC < 1K/uL, and the second cycle resulted in WBC < 1K/uL since 2023-07-24, which has not yet returned to levels above 1K/uL. Thrombocytopenia was previously mentioned in the pharmacist’s note. The HGB levels show a similar trend to the PLT levels. In addition, the patient has received several blood transfusions this year on different dates (2023-01-02, 2023-01-06, 2023-01-11, 2023-01-18, 2023-01-22, 2023-01-26, 2023-01-28, 2023-01-30, 2023-02-03, 2023-03-03, 2023-03-07, 2023-03-11, 2023-03-17, 2023-04-14, 2023-04-18, 2023-04-22, 2023-04-26, 2023-04-30, 2023-06-19, 2023-06-28, 2023-07-17, 2023-07-21, 2023-07-25) and also received G-CSF in the first quarter of this year.
The FLAG regimen was initiated on 2023-06-21. However, the current thrombocytopenia event had started even before the regimen was administered. Visually estimating the platelet count before and after the FLAG administration, the values were approximately within the range of 50 +- 25 K/uL, and there was no clear downward trend. This is because the patient had received multiple transfusions to maintain PLT a certain level.
2023-07-06 PLT 55 x10^3/uL
2023-07-04 PLT 25 x10^3/uL
2023-07-02 PLT 48 x10^3/uL
2023-06-30 PLT 23 x10^3/uL
2023-06-28 PLT 62 x10^3/uL Blood Transfution
2023-06-26 PLT 37 x10^3/uL
2023-06-25 PLT 47 x10^3/uL
2023-06-24 PLT 73 x10^3/uL
2023-06-23 PLT 28 x10^3/uL Blood Transfution 2023-06-22 PLT 40
x10^3/uL
2023-06-21 PLT 54 x10^3/uL FLAG 2023-06-20 PLT 47 x10^3/uL
2023-06-19 PLT 19 x10^3/uL Blood Transfution 2023-06-08 PLT 70
x10^3/uL
2023-05-04 PLT 247 x10^3/uL
2023-05-02 PLT 176 x10^3/uL
2023-05-01 PLT 137 x10^3/uL Blood Transfution (2023-04-30)
The risk of bleeding generally increases with platelet counts below 40 to 50 K/uL, but there isn’t a strong linear correlation between platelet count and bleeding risk. If major or life-threatening bleeding occurs, platelet transfusions should be administered without delay.
[FLT3 inhibitors]
Laboratory data from 2023-01-12 and 2023-06-28 indicated the presence of FLT3/ITD mutation.
There are two FDA approved FLT3 inhibitors for AML included in the National Health Insurance Medication Reimbursement Regulations, namely:
Currently, Rydapt is a temporarily procured drug at our hospital, and Xospata does not have a built drug code yet. If any of these two drugs is considered further use, a temporary procurement procedure must be carried out.
[neutropenia follow-up]
[leukopenia]
On 2023-01-09, the patient started a regimen containing anthracycline and cytarabine (idarubicin for 3 days + cytarabine for 7 days), which led to more than 2 weeks of leucopenia with a WBC count of less than 1000/uL. More than 5 weeks later, on 2023-02-23, the second dose was shifted to daunorubicin for 3 days and cytarabine for 7 days. This time, the duration of WBC less than 1000/uL was approximately halved to 1 week. Although the patient was administered G-CSF (filgrastim 150ug) and Granocyte (lenograstim 250ug) on 2023-03-03, WBC count did not appear to increase soon after.
On 2023-04-07, the patient received daunorubicin for 3 days and cytarabine for 5 days at a more intensive dose of 2000mg/m2 amounting to 4000mg every 12 hours. After the administration, the WBC count has not dropped below 1000/uL and there has been a reduction in the severity of leukopenia to date.
WBC lab data
[lab data]
2023-07-27 LDH 150 U/L
2023-07-20 B2-Microglobulin 2197 ng/mL
2023-07-18 BM chromosome analysis - cytogenetics laboratory report
2023-07-13 B2-Microglobulin 2254 ng/mL
2023-07-12 LDH 142 U/L
2023-06-21 Anti-HBc Reactive
2023-06-21 Anti-HBc-Value 4.63 S/CO
2023-06-21 Anti-HBs 297.01 mIU/mL
2023-06-21 HBsAg Nonreactive
2023-06-21 HBsAg (Value) 0.35 S/CO
[exam findings]
[MedRec]
[immunochemotherapy]
[Dipeptiven dosage and administration]
(Dipeptiven ref: https://www.fresenius-kabi.com/nz/documents/Dipeptiven_Datasheet.pdf)
Solution for infusion after mixture with a compatible infusion solution. Solutions of mixtures with an osmolarity above 800 mosmol/L should be infused by the central venous route.
Dipeptiven is administered parallel with parenteral nutrition or enteral nutrition or a combination of both. Dosage depends on the severity of the catabolic state and on amino acids/protein requirement.
A maximum daily dosage of 2 g amino acids/or protein per kg bodyweight should not be exceeded in parenteral/enteral nutrition. The supply of alanine and glutamine via Dipeptiven should be taken into consideration in the calculation. The proportion of the amino acids supplied through Dipeptiven should not exceed approx. 30% of the total amino acids/protein supply.
[Selection of antiviral drugs for Hepatitis B]
This patient is undergoing dialysis, and the current administration methods for Hepatitis B medication available in our hospital for dialysis patients are:
Considering the patient’s bilirubin levels on 2023-08-30, with total bilirubin at 2.32mg/dL and direct bilirubin at 1.78mg/dL, the use of Baraclude 0.5mg QWAC may be an option.
The patient renewed his prescription on 2023-08-03 for metformin, aspirin, bisoprolol, amlodipine, and atorvastatin. Comparing with the active medication list, statins are not listed. Lab results from 2023-08-04 indicated no hyperlipidemia. Thus, there are no identified issues with medication reconciliation.
2023-08-04 Cholesterol total 148 mg/dL
2023-08-04 Triglyceride (TG) 95 mg/dL
2023-08-04 LDL-C 95 mg/dL
2023-08-04 HDL-C 43 mg/dL
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
Based on PharmaCloud records, this patient has only received medical care at our hospital in the last three months, with no medication reconciliation issues identified.
從 PharmaCloud 紀錄來看，該名患者最近三個月只在本院就診，沒有發現 medication reconciliation issue.
[lab data]
2023-08-14 CMV viral load assay Target not detecetedIU/mL
2023-08-09 CD45+Total leukocyte 329085 /uL
2023-08-09 %CD34+ 0.41 %
2023-08-09 CD34+ Count 1350 /uL
2023-08-09 CD45+Total leukocyte 25806 /uL
2023-08-09 %CD34+ 0.10 %
2023-08-09 CD34+ Count 26 /uL
2023-08-09 HPC Ratio 0.41 %
2023-08-09 HPC# 0.1050 10^3/ul
2023-08-08 CD45+Total leukocyte 367310 /uL
2023-08-08 %CD34+ 0.31 %
2023-08-08 CD34+ Count 1140.0 /uL
2023-08-08 RPR/VDRL Nonreactive
2023-08-08 HIV Ab-EIA Nonreactive
2023-08-08 Anti-HIV Value 0.07 S/CO
2023-08-08 Anti-HCV Nonreactive
2023-08-08 Anti-HCV Value 0.09 S/CO
2023-08-08 HBsAg Nonreactive
2023-08-08 HBsAg (Value) 0.27 S/CO
2023-08-08 CD45+Total leukocyte 22719 /uL
2023-08-08 %CD34+ 0.10 %
2023-08-08 CD34+ Count 24.0 /uL
2023-08-08 HPC Ratio 0.34 %
2023-08-08 HPC# 0.0820 10^3/ul
2023-07-18 IgG (blood) 732 mg/dL
2023-06-06 Free Light Chain κ/λ, (blood) ratio
2023-06-06 FKLC 9.6 mg/L
2023-06-06 FLLC 86.8 mg/L
2023-06-06 FK/FL ratio 0.11 ratio
2023-06-01 B2-Microglobulin 1862 ng/mL
2023-05-31 IgG (blood) 867 mg/dL
2023-05-23 CD45+Total leukocyte 216525 /uL
2023-05-23 %CD34+ 0.13 %
2023-05-23 CD34+ Count 285 /uL
2023-05-23 CD45+Total leukocyte 36136 /uL
2023-05-23 %CD34+ 0.02 %
2023-05-23 CD34+ Count 6 /uL
2023-05-23 HPC Ratio 0.04 %
2023-05-23 HPC# 0.018 10^3/ul
2023-05-22 CD45+Total leukocyte 243730 /uL
2023-05-22 %CD34+ 0.31 %
2023-05-22 CD34+ Count 760 /uL
2023-05-22 HPC Ratio 0.18 %
2023-05-22 HPC# 0.094 10^3/ul
2023-05-03 Free Light Chain κ/λ; (blood) ratio
2023-05-03 FKLC 11.2 mg/L
2023-05-03 FLLC 53.5 mg/L
2023-05-03 FK/FL ratio 0.21 ratio
2023-04-27 B2-Microglobulin 1275 ng/mL
2023-04-26 IgG (blood) 782 mg/dL
2023-04-11 CD45+Total leukocyte 246285 /uL
2023-04-11 %CD34+ 0.08 %
2023-04-11 CD34+ Count 200 /uL
2023-04-11 CD45+Total leukocyte 24252 /uL
2023-04-11 %CD34+ 0.01 %
2023-04-11 CD34+ Count 2 /uL
2023-04-11 HPC Ratio 0.15 %
2023-04-11 HPC# 0.036 10^3/ul
2023-04-10 CD45+Total leukocyte 191835 /uL
2023-04-10 %CD34+ 0.11 %
2023-04-10 CD34+ Count 205 /uL
2023-04-10 CD45+Total leukocyte 30658 /uL
2023-04-10 %CD34+ 0.02 %
2023-04-10 CD34+ Count 6 /uL
2023-04-10 HPC Ratio 0.21 %
2023-04-10 HPC# 0.062 10^3/ul
2023-03-31 Free Light Chain κ/λ; (blood) ratio
2023-03-31 FKLC 9.4 mg/L
2023-03-31 FLLC 55.1 mg/L
2023-03-31 FK/FL ratio 0.17 ratio
2023-03-25 B2-Microglobulin 1833 ng/mL
2023-03-24 IgG (blood) 621 mg/dL
2023-03-13 Free Light Chain κ/λ; (blood) ratio
2023-03-13 FKLC 9.6 mg/L
2023-03-13 FLLC 87.3 mg/L
2023-03-13 FK/FL ratio 0.11 ratio
2023-03-04 B2-Microglobulin 1701 ng/mL
2023-03-03 IgG (blood) 880 mg/dL
2023-02-23 Influenza A Ag Negative
2023-02-23 Influenza B Ag Negative
2023-02-08 Free Light Chain κ/λ; (blood) ratio
2023-02-08 FKLC 15.1 mg/L
2023-02-08 FLLC 231.25 mg/L
2023-02-08 FK/FL ratio 0.07 ratio
2023-02-04 B2-Microglobulin 2002 ng/mL
2023-02-03 IgG (blood) 757 mg/dL
2022-12-22 Free Light Chain κ/λ; (blood) ratio
2022-12-22 FKLC 13.4 mg/L
2022-12-22 FLLC 287.5 mg/L
2022-12-22 FK/FL ratio 0.05 ratio
2022-12-17 B2-Microglobulin 2642 ng/mL
2022-12-16 IgG (blood) 1463 mg/dL
2022-11-29 HBsAg Nonreactive
2022-11-29 HBsAg (Value) 0.41 S/CO
2022-11-29 Anti-HCV Nonreactive
2022-11-29 Anti-HCV Value 0.24 S/CO
2022-11-29 Anti-HBc Reactive
2022-11-29 Anti-HBc-Value 6.61 S/CO
2022-11-29 Anti-HBc IgM Nonreactive
2022-11-29 Anti-HBc IgM Value 0.09 S/CO
2022-11-29 Anti-HBs 9.54 mIU/mL
2022-11-24 CD2 NA
2022-11-24 CD3 61.7
2022-11-24 CD4 19.9
2022-11-24 CD5 75.6
2022-11-24 CD7 82.3
2022-11-24 CD8 52.2
2022-11-24 CD10 12.5
2022-11-24 CD11b NA
2022-11-24 CD13 NA
2022-11-24 CD14 3.9
2022-11-24 CD15 NA
2022-11-24 CD16 NA
2022-11-24 CD19 19.5
2022-11-24 CD19/kappa 7.27
2022-11-24 CD19/Lambda 9.4
2022-11-24 CD20 25.7
2022-11-24 CD23 18.9
2022-11-24 CD25 16.5
2022-11-24 CD33 NA
2022-11-24 CD34 6.9
2022-11-24 CD38 85.2
2022-11-24 CD56 29.1
2022-11-24 CD103 NA
2022-11-24 CD117 NA
2022-11-24 CD138 16.2
2022-11-24 FMC7 19.3
2022-11-24 HLA-DR NA
2022-11-24 MPO NA
2022-11-24 TdT NA
2022-11-23 BM chromosome analyz see attachment
2022-11-10 Free Light Chain κ/λ; (urine)
2022-11-10 Total Volume(24hr) 4500 mL
2022-11-10 FKLC 28.8 mg/L
2022-11-10 FLLC 6875 mg/L
2022-11-10 FK/FL ratio 0.004189
2022-11-08 IgD; <46.7 U/mL
2022-11-08 Free Light Chain κ/λ; (blood) ratio
2022-11-08 FKLC 14.0 mg/L
2022-11-08 FLLC 2725 mg/L
2022-11-08 FK/FL ratio 0.01 ratio
2022-11-07 Protein EP; (urine)
2022-11-07 Protein (Urine) 334 mg/dL
2022-11-07 Albumin(Urine) 4.8 %
2022-11-07 Alpha-1 0.9 %
2022-11-07 Alpha-2 1.1 %
2022-11-07 Beta 2.8 %
2022-11-07 Gamma 90.4 %
2022-11-07 A/G Ratio (Urine) 0.1
2022-11-05 Protein EP;
2022-11-05 Protein, total 8.8 g/dL
2022-11-05 Albumin 35.0 %
2022-11-05 Alpha-1 1.8 %
2022-11-05 Alpha-2 9.7 %
2022-11-05 Beta 8.6 %
2022-11-05 Gamma 44.9 %
2022-11-05 M-peak Positive
2022-11-05 A/G Ratio 0.50
2022-11-05 Protein, total 9.0 g/dL
2022-11-05 Albumin 35.3 %
2022-11-05 Alpha-1 2.4 %
2022-11-05 Alpha-2 9.5 %
2022-11-05 Beta 8.5 %
2022-11-05 Gamma 44.3 %
2022-11-05 M-peak Positive
2022-11-05 A/G Ratio 0.50
2022-11-05 IgG/A/M Kappa/Lambda IgG + Lambda chain
2022-11-05 IgE 13.4 IU/mL
2022-11-04 B2-Microglobulin 2800 ng/mL
2022-11-03 IgG (blood) 4374 mg/dL
2022-11-03 IgA 95 mg/dL
2022-11-03 IgM 34.0 mg/dL
2022-11-03 Total protein 9.4 g/dL
[MedRec]
[family meeting minutes prior to ASCT]
On 2023-08-30 at 10:15 in the ward conference room, Dr. Gao chaired a family meeting with the patient and his relatives. Attendees included the patient himself, his wife, and his daughter, while his son joined via phone. Dr. Gao explained the treatment plan, the importance and potential risks of autologous stem cell transplantation as a treatment method, and allowed family members to ask questions freely during the meeting.
Overall, the family seemed supportive, and the patient indicated that he would be willing to use a nasogastric tube if necessary during the transplantation treatment. His daughter asked if mouthwash could alleviate symptoms of oral mucositis, to which Dr. Gao responded that mouthwash could help maintain oral cleanliness but couldn’t completely prevent or mitigate the condition, which is mainly caused by conditioning agents.
After the meeting, some casual conversation with the family revealed that the patient was a chef and had run his own business in the past. After retiring, he assisted with religious services in several temples. He is also a vegetarian and has no objections to the hospital’s food offerings.
[Evomela (melphalan) as conditioning regimen prior to HSCT for multiple myeloma]
The recommended dosing schedule is IV 100 mg/m2 daily for 2 days on day -3 and day -2 prior to autologous stem cell transplantation on day 0. Ref: Hari P, Aljitawi OS, Arce-Lara C, et al. A Phase IIb, Multicenter, Open-Label, Safety, and Efficacy Study of High-Dose, Propylene Glycol-Free Melphalan Hydrochloride for Injection (EVOMELA) for Myeloablative Conditioning in Multiple Myeloma Patients Undergoing Autologous Transplantation. Biol Blood Marrow Transplant. 2015;21(12):2100-2105. doi:10.1016/j.bbmt.2015.08.026
[MedRec]
[chemotherapy]
In the last three months, all medical records on PharmaCloud are from this hospital. Currently, no medication reconciliation issues have been identified.
(not completed)
[MedRec]
[immunochemotherapy]
On 2023-07-09, the patient refilled her repeat prescription for atenolol and valsartan to manage her primary hypertension. This prescription was originally issued by JingMei Hospital on 2023-06-15. Both medications have been added to the active medication list, and there are no reconciliation issues detected.
[MedRec]
[surgical operation]
[chemotherapy]
[immunochemotherapy]
2023-08-07 - trastuzumab 6mg/kg 330mg NS 250mL 90min (Chang YaoRen)
2023-07-19 - trastuzumab 6mg/kg 330mg NS 250mL 90min (Chang YaoRen)
2023-07-05 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)
2023-06-28 - trastuzumab 6mg/kg 330mg NS 250mL 90min (Chang YaoRen)
2023-06-21 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)
2023-06-14 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)
2023-06-07 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)
2023-06-07 - trastuzumab 6mg/kg 350mg NS 250mL 90min (Chang YaoRen)
2023-02-10 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)
2023-01-27 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)
2023-01-12 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)
2022-12-29 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)
2022-12-07 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-11-16 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-10-26 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-10-05 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-09-14 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-08-24 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-08-03 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-07-13 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-06-22 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-05-25 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2022-05-04 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2023-04-13 - trastuzumab 6mg/kg 390mg NS 250mL 90min
2023-03-23 - trastuzumab 6mg/kg 375mg NS 250mL 90min
2022-03-02 - trastuzumab 6mg/kg 360mg NS 250mL 90min
2022-02-09 - trastuzumab 6mg/kg 360mg NS 250mL 90min
2022-01-19 - trastuzumab 6mg/kg 360mg NS 250mL 90min
2021-12-29
2021-12-08
2021-11-17
2021-10-27
2021-10-06
2021-09-15
2021-08-25
2021-08-04
2021-07-14
2021-06-23
2021-06-02
2021-05-05
2021-04-14
2021-03-24
2021-03-03 - trastuzumab emtansine 230mg NS 250mL 1.5hr
2021-02-10 - trastuzumab emtansine 230mg NS 250mL 1.5hr
2021-01-11
2020-12-21
2020-11-30
2020-11-09
2020-10-19
2020-09-28
2020-09-07
2020-08-17
2020-07-27
2020-07-06
2020-06-22
2020-06-15
2020-06-03
2020-05-27
2020-05-13
2020-05-06
2020-04-22
2020-04-15
2020-04-01 - eribulin 1.4mg/m2 2.4mg NS 50mL 10min
2020-03-25 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + eribulin 1.4mg/m2 2.4mg NS 50mL 10min
2020-03-11 - eribulin 1.4mg/m2 2.4mg NS 50mL 10min
2020-03-04 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 1hr + eribulin 1.4mg/m2 2.4mg NS 50mL 10min
2020-02-10 - trastuzumab 600mg SC 5min
2020-01-20 - trastuzumab 600mg SC 5min
[cachexia]
The patient has lost 10 kg in three months, from 63.2 kg on 2023-05-25 to 52.5 kg on 2023-08-11. To combat this significant weight loss, it’s important to improve the patient’s nutritional intake. In the absence of dysphagia, megestrol can be introduced as an appetite stimulant at a suggested dosage of 200 to 600 mg/day to counteract anorexia.
[oral mucotitis]
For oral mucotitis, the introduction of Nincort Oral Gel (triamcinolone) is recommended to relieve discomfort.
[MedRec]
The patient renewed a repeat prescription for insulin degludec, linagliptin, clopidogrel, doxazosin, bisoprolol, pitavastatin, levothyroxine, and ginkgo biloba extract on 2023-08-04. Some of these medications are not listed in the active medication list. Please verify if the unlisted medications are no longer required.
[exam findings]
[MedRec]
There are no medication reconciliation issues identified after reviewing the PharmaCloud database and HIS5 records.
[exam findings]
[consultation]
[surgical operation]
[immunochemotherapy]
No medication reconciliation issues were identified after reviewing PharmaCloud and HIS5 records.
The repeat prescription issued by NTUH was refilled on 2023-08-01 and includes Norvasc (amlodipine), Aprovel (irbesartan), Lipitor (atorvastatin), and Xanax (alprazolam). These medications are currently being used with no reconciliation issues identified.
This patient visited NTUH on 2023-06-15 and was prescribed Norvasc (amlodipine), Aprovel (irbesartan), Lipitor (atorvastatin), Xanax (alprazolam) which were refilled at a local pharmacy on 2023-07-03. These drugs are now in the active medication list, no reconciliation issues found.
Upon examining the PharmaCloud database, it appears that access to this patient’s information is currently unavailable, potentially due to lack of authorization. However, a review of the HIS5 medication records indicates that all valid prescriptions were provided by the Hemato-Oncology department. Hence, no medication reconciliation issues have been found.
[exam findings]
[MedRec]
This patient received a repeat prescription on 2023-06-28 at NTUH HsinChu Branch and refilled it on 2023-07-20 at a local pharmacy for a 28-day supply of Sennapur (sennoside), Betmiga (mirabegron), Xanax (alprazolam), and Eurodin (estazolam). There is no mirabegron included in the active medication list, please confirm if the drug is no longer needed.
[MedRec]
[MedRec]
[MedRec]
[radiotherapy]
[chemotherapy]
[lab data]
2023-05-19 Anti-HBs 1.62 mIU/mL
2023-05-19 Anti-HCV Nonreactive
2023-05-19 Anti-HCV Value 0.12 S/CO
2023-05-19 HBsAg Reactive
2023-05-19 HBsAg (Value) 3220.93 S/CO
2023-05-19 Anti-HBc Reactive
2023-05-19 Anti-HBc-Value 8.80 S/CO
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
No reconciliation issues found after reviewing PharmaCloud and HIS5 records.
As of 2023-05-19, the patient has tested reactive for Anti-HBc. Baraclude (entecavir 0.5mg) 1# QDAC has been appropriately prescribed. The patient’s vital signs are currently stable and there are no issues with the active prescription.
[exam findings]
[consultation]
[radiotherapy]
[chemotherapy]
After reviewing the PharmaCloud database and in-hospital HIS5 records, no medication reconciliation issues were identified.
[diagnosis] - 2023-03-22 discharge note
[past history] - 2023-04-05 admission note
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
2023-08-11 Radiation Oncology
2023-08-11 Family Medicine
2023-08-11 Ear Nose Throat
2023-04-07 Infectious Disease
2023-04-07 Chest Medicine
2023-04-07 Cardiology
2023-02-22 Vascular Surgery
[chemotherapy]
[tube feeding: Detrusitol SR (tolterodine), Valcyte F.C (valganciclovir)]
Based on the information for Valcyte F.C (valganciclovir), the drug should not be crushed for tube feeding because animal data suggests that valganciclovir has the potential to be carcinogenic in humans. As this hospital does not have access to foscarnet or cidofovir, and ganciclovir shares a similar potential carcinogenic risk, it seems that continuing with Valcyte for tube feeding is the only option at this stage.
Detrusitol SR (tolterodine) is an extended-release capsule, and crushing it for tube feeding could compromise its prolonged-release properties. This could result in a more pronounced fluctuation in its concentration in the bloodstream, potentially affecting its therapeutic efficacy. All other in-hospital available drugs within the same class as tolterodine, such as Urotrol F.C (propiverine 15mg), Oxbu ER (oxybutynin 5mg), Vesicare F.C (solifenacin 5mg), and Betmiga (mirabegron 50mg), are designed as film-coated or extended-release. It might be beneficial to divide the dosage of Detrusitol into two administrations per day to stabilize the concentration in the bloodstream for tube feeding.
Patients undergoing treatment with immunosuppressive drugs are at an increased risk of developing Pneumocystis pneumonia (PCP). This risk is particularly heightened in patients who are receiving glucocorticoids in combination with cytotoxic agents such as cyclophosphamide, and in those receiving multiple chemotherapeutic agents, especially during periods of leukopenia. As a measure against PCP, the patient has been prescribed Morcasin (containing trimethoprim 80mg and sulfamethoxazole 400mg, also known as TMP-SMX). Given that the patient doesn’t show signs of renal insufficiency (based on 2023-05-15 lab data), there is no need for a dose adjustment.
Lab data reveals that the patient’s CMV viral load, which had peaked at 803 IU/mL on 2023-05-02, has now decreased to less than 35 IU/mL as of today, 2023-05-15. Valganciclovir, the active ingredient in Valcyte, is an oral prodrug that is rapidly converted into ganciclovir, a substance instrumental in the treatment and prevention of CMV infections in immunocompromised hosts. The marked decrease in CMV viral load suggests that the prescribed Valcyte is effectively managing the CMV infection.
As per the PharmaCloud records, all of the patient’s recent medications have been prescribed by our hospital, and no issues related to medication reconciliation have been identified.
2023-04-05 lab data showed elevated CRP, NT-proBNP, hs-Troponin I, D-dimer, as well as hyponatremia, leukopenia and anemia. Liver and kidney functions were normal. Cardiologist has been consulted.
Pneumonia with exaggerated dyspnea and hypoxemia was observed on admission; planned chemotherapy is withheld until respiratory symptoms resolve. Brosym (cefoperazone + sulbactam) has been prescribed since the day the patient was admitted.
Rivaroxaban and amlodipine have been prescribed properly as self-carried items with no medication reconciliation issues.
[exam findings]
[consultation]
[chemoimmunotherapy]
[exam findings]
[MedRec]
2023-08-10 SOAP Radiation Oncology
2023-08-02 SOAP Hemato-Oncology Xia HeXiong
2023-07-27 SOAP Hemato-Oncology Gao WeiYao
2023-07-27 SOAP Radiation Oncology
2023-07-19 ~ 2023-07-20 POMR Gastroenterology
2023-07-04 SOAP Hemato-Oncology Gao WeiYao
2023-07-04 SOAP Radiation Oncology
2023-06-21 SOAP Cardiology
2023-06-20 SOAP Metabolism and Endocrinology
[consultation]
[radiotherapy]
[chemotherapy]
[reconciliation]
A repeat prescription was issued by our cardiologist on 2023-06-21 and was refilled on 2023-08-06 for Algitab (alginic acid, MgCO3, Al(OH)3), Eurodin (estazolam), Concor (bisoprolol), and Sevikar (amlodipine 5mg, olmesartan 20mg). All of these refilled drugs, except for Algitab, have been included in the formulary. Please confirm whether Algitab is still necessary for the patient.
[FDG-PET/CT in detecting cancers with unknown primary site depends on histological subtype]
On 2023-07-20, the pathologic analysis results of the liver biopsy needle/wedge did not reveal any evidence of hepatocytic or cholangiocytic differentiation based on ICH staining. Therefore, the primary origin of the condition remains unidentified. An article titled “The usefulness of FDG-PET/CT in detecting and managing cancers with unknown primary site depends on histological subtype. Sci Rep. 2021;11(1):17732. Published 2021 Sep 6” highlighted the following key points:
In light of this, the use of PET could be an optional tool to help identify the origin of the biopsy liver lesion.
[diagnosis] - 2023-05-02 admission note
[past history]
Medical history: - Hypertension under Losa & hydro control for more than ten years - Type 2 diabetes mellitus under Dibose and Trajenta contro for two months - Hypothyrodism without medical control for over three years. - Hyperlipidemia with Zulitor F.C 4mg 0.5# po QD - Cerebral atherosclerosis with Plavix F.C 75mg 1# po QD
Surgical history: - Left knee osteoarthritis status post left total knee replacement on 2016. - Gastric perforation status post Billroth II for many years.
[allergy]
[family history]
[exam findings]
[consultation]
[MedRec]
[chemoimmunotherapy]
Revised Edition of Hematologic Oncology Chemotherapy Drug Prescription (in hospital regimen collection, version 2022-07-04)
Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP21) for non-Hodgkin lymphoma 2023-06-06 https://www.uptodate.com/contents/image?imageKey=ONC%2F63586&topicKey=HEME%2F4729
Cycle length: 21 days.
Regimen
Pretreatment considerations:
Monitoring parameters:
Suggested dose modifications for toxicity:
Older patients with DLBCL generally have a worse prognosis compared to younger patients due, in part, to more comorbid conditions and lower treatment tolerance. 2023-06-06 https://www.uptodate.com/contents/initial-treatment-of-advanced-stage-diffuse-large-b-cell-lymphoma
Our endocrinologist wrote a repeat prescription for Zulitor (pitavastatin), Trajenta (linagliptin 5mg) and Dibose (acarbose 100mg) on 2023-08-02 and the drugs are included in the formulary with no reconciliation issue identified.
On 2023-06-08, our neurologist issued a refillable prescription for Plavix (clopidogrel) and diphenidol, and on 2023-06-23, our otolaryngologist prescribed Strocain (oxethazaine polymigel), Acetal (acetaminophen), and cephalexin. Apart from diphenidol, which is no longer necessary due to the resolution of vertigo, all other validly prescribed drugs mentioned have been incorporated into the active medication list without any reconciliation issues.
This patient visited local medical doctor on 2023-05-26, 2023-05-28, 2023-05-29, 2023-05-30, 2023-06-01, 2023-06-04 for her myositis, functional dyspepsia, acute upper respiratory infection, and prescribed acetaminophen, diazepam, loratadine and opium derivatives. for each a short 3-day valid prescription. These symptoms are generally covered in current medical problem list and managed with corresponding same or similar therapeutic class medications. No medication reconciliation issues identified.
Given that this patient has been diagnosed with myositis and dyspepsia that have persisted for months according to the PharmaCloud database, it’s plausible that these could be indicative of statin-induced muscle side effects. Clinical experience suggests that a change in dosing frequency, such as alternate day dosing, may improve statin tolerability in patients experiencing adverse effects such as myalgia. This strategy is particularly beneficial for patients who cannot tolerate daily statin therapy. In addition, alternate-day statin therapy is also considered a cost-effective method to improve drug utilization (Ref: Efficacy and Safety of Alternate-Day Versus Daily Dosing of Statins: a Systematic Review and Meta-Analysis. Cardiovasc Drugs Ther. 2017;31(4):419-431). Considering the information from these studies and the fact that the laboratory data indicate an improvement in the patient’s hyperlipidemia, it is recommended that the administration of Zulitor be changed from 0.5# QD to 0.5# QOD.
Due to the patient’s advanced age, R-miniCHOP (a dose-reduced version of R-CHOP with reduced amounts of cyclophosphamide and vincristine) was selected as treatment starting on 2023-03-31. One episode of leukopenia was observed (1.56K/uL on 2023-04-12) and was alleviated with two consecutive days of Granocyte (lenograstim) administration. Please monitor for recurrence of leukopenia after this 2nd dose of R-miniCHOP.
Beta-2 microglobulin (b2M) is a major histocompatibility complex (MHC) class I molecule found on the surface of nearly all nucleated cells in the body. Cells with a high turnover rate, such as immune cells and cancer cells, tend to produce and express higher levels of b2M on their surface. In non-Hodgkin’s lymphoma, cancer cells may also have elevated levels of b2M. The elevated levels of b2M observed around the trough of leukopenia may indicate the destruction of cancerous B cells.
Lab data showed that levels above the ULN are associated with type 2 diabetes and hyperlipidemia. Dibose (acarbose), Trajenta (linagliptin) and Zulitor (pitavastatin) are currently appropriately prescribed.
The patient’s cerebral atherosclerosis is treated with Plavix (clopidogrel) and her hepatitis B is treated with Baraclude (entecavir) without an issue.
Hypothyroidism is listed as a diagnosis for the patient, but there is no corresponding medication prescribed currently. The serum free T4 level on 2023-03-17 was 0.57 ng/dL, which is slightly below the normal range. It is recommended to reevaluate the patient’s condition and consider prescribing appropriate medication, such as levothyroxine, if necessary to manage her hypothyroidism.
[drug identification]
The three requested drugs have been identified as follows:
An in-hospital porter will be sent to deliver these medications to the patient’s ward.
[exam findings]
[MedRec]
2023-07-10 SOAP Colorectal Surgery
2020-06-16 SOAP Metabolism and Endocrinology
2018-12-04 SOAP Colorectal Surgery
2018-11-05 SOAP Colorectal Surgery
2017-03-06 SOAP Metabolism and Endocrinology
[chemotherapy]
On 2023-08-01, this patient obtained a 28-day supply of metformin, repaglinide, bisoprolol, olmesartan, and pitavastatin from Cheng Hsin General Hospital. It is noted that GLP-1 agonist (such as semaglutide) and HMG-CoA reductase inhibitor (like pitavastatin) are not currently listed in the active medication profile. It is advisable to closely observe the patient’s blood lipid and blood sugar levels to determine whether these medications or similar drugs within the same therapeutic class are necessary for his ongoing treatment.
[lab data]
2023-08-10 Anti-β2-glycoprotein-I Ab 0.6 U/mL
2023-08-10 Anti-cardiolopin IgG 0.7 GPL-U/mL
2023-08-10 Anti-cardiolipin IgM 1.3 MPL-U/mL
2023-08-08 CEA (NM) 89.031 ng/ml
2023-08-07 HBsAg Nonreactive
2023-08-07 HBsAg (Value) 0.36 S/CO
2023-08-07 Anti-HBc Reactive
2023-08-07 Anti-HBc-Value 6.47 S/CO
2023-08-07 Anti-HCV Nonreactive
2023-08-07 Anti-HCV Value 0.09 S/CO
2023-08-07 CEA 96.78 ng/mL
2023-08-07 CA199 29.24 U/mL
2023-08-07 D-dimer > 10000.00 ng/mL(FEU)
2023-08-07 PT 11.1 sec
2023-08-07 INR 1.08
2023-08-07 APTT 25.7 sec
2023-08-07 Fibrinogen(quantita) 364.4 mg/dL
2023-08-04 Alkaline phosphatase 931 U/L
[exam findings]
[MedRec]
[lab data]
2023-07-26 Anti-HBc Reactive
2023-07-26 Anti-HBc-Value 6.35 S/CO
2023-07-26 Anti-HBs 7.41 mIU/mL
2023-07-26 Anti-HCV Nonreactive
2023-07-26 Anti-HCV Value 0.23 S/CO
2023-07-26 HBsAg Nonreactive
2023-07-26 HBsAg (Value) 0.26 S/CO
[exam findings]
[MedRec]
[lab data]
2023-07-22 Anti-HBc Reactive
2023-07-22 Anti-HBc-Value 4.23 S/CO
2023-07-22 Anti-HCV Nonreactive
2023-07-22 Anti-HCV Value 0.13 S/CO
2023-07-22 Anti-HBs 5.84 mIU/mL
2023-07-22 HBsAg Nonreactive
2023-07-22 HBsAg (Value) 0.49 S/CO
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[prophylactic antiviral therapy prior to immunosuppressive agent use]
The patient’s hepatitis B serology results indicate that he is immune due to natural infection, with negative HBsAg, positive anti-HBc, and positive anti-HBs. However, he remains vulnerable to reactivation if exposed to immunosuppressive agents.
Given this situation, if the treatment plan involves immunosuppressive agents, it is advisable to consider prophylactic antiviral therapy. Possible options include prescribing either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD. This preventive approach can effectively lower the risk of potential HBV reactivation induced by the immunosuppressive effects of the treatment.
ref: Pharmacy FAQ - Hepatitis B reactivation and screening. http://www.bccancer.bc.ca/pharmacy-site/Documents/Pharmacy%20FAQs/Pharmacy-FAQ-Hepatitis-B.pdf
[MedRec]
Concor (bisoprolol) and Nexium (esomeprazole) should be prepared by the simple suspension method before tube feeding.
The simple suspension method refers to the process of placing tablets and capsules in warm water for a period of time and gently shaking them to promote disintegration and suspension of the medication, rather than grinding them into powder for tube feeding.
{rectal cancer with LNs, lung, sacrum, sacroiliac joints mets, stage IV}
[lab data]
2023-07-19 HBsAg (NM) Negative
2023-07-19 HBsAg Value (NM) 0.420
2023-07-19 Anti-HBs (NM) Negative
2023-07-19 Anti-HBs value (NM) <2.000 mIU/mL
2023-07-19 Anti-HBc (NM) Negative
2023-07-19 Anti-HBc Value (NM) 2.190
2021-06-02 KRAS 12/13 Sample No S2021-6919
2021-06-02 KRAS 12/13 mutation detected
2021-06-02 NRAS/KRAS Sample No S2021-6919
2021-06-02 NRAS/KRAS mutation Not detected
2021-05-14 HBsAg Nonreactive
2021-05-14 HBsAg (Value) 0.34 S/CO
2021-05-14 Anti-HBc Nonreactive
2021-05-14 Anti-HBc-Value 0.44 S/CO
2021-05-14 Anti-HCV Nonreactive
2021-05-14 Anti-HCV Value 0.06 S/CO
[exam finding]
[MedRec]
[chemoimmunotherapy]
2023-08-07 - irinotecan 180mg/m2 175mg D5W 250mL 90min + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2800mg/m2 4535mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)
2023-07-24 - irinotecan 180mg/m2 175mg D5W 250mL 90min + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2800mg/m2 4535mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)
2023-07-10 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)
2023-06-26 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)
2023-06-13 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)
2023-05-30 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)
2023-05-12 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)
2023-04-21 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea)
2023-04-03 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea)
2023-03-09 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W)
2023-02-21 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W)
2022-09-19 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)
2022-09-01 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)
2022-08-14 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)
2022-08-01 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)
2022-07-11 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)
2022-06-27 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 157mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)
2022-06-06 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 336mg 1.5hr + leucovorin 400mg/m2 748mg 2hr + fluorouracil 2800mg/m2 5235mg 46hr
2022-05-19 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 330mg 1.5hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5190mg 46hr
2022-04-29 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 330mg 1.5hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5190mg 46hr
2022-04-15 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 330mg 1.5hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 2800mg/m2 5130mg 46hr
2022-03-23 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 347mg 1.5hr + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr
2022-03-09 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 347mg 1.5hr + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr
2022-02-22 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 348mg 1.5hr + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr
2022-02-08 - irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
2022-01-18 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
2022-01-04 - bevacizumab 5mg/kg 380mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
2021-06-29 ~ 2022-01-18 - FOLFIRI + bevacizumab
2021-05-13 ~ 2021-06-11 - FOLFIRI
[anemia]
Since 2023-02, the patient has been receiving FOLFIRI regimen. On 2023-08-06, there was an episode of grade 3 anemia (HGB < 8 g/dL) (another grade 3 anemia was recorded on 2023-04-03 with a HGB level of 7.6g/dL). To address the anemia, blood transfusions were administered on 2023-03-14, 2023-04-03, 2023-05-12, and 2023-08-06.
Starting from 2023-04-03, the dose of Irinotecan was reduced to 60% (300mg -> 180mg -> 175mg).
According to the PharmaCloud database, this patient has only received his medical needs from our hospital in the past 3 months, no medication reconciliation issues identified.
[exam findings]
[surgical operation]
[MedRec]
[radiotherapy]
[chemotherapy]
The package insert for Dicetel (pinaverium bromide) advises against oral ingestion or chewing. It is recommended to swallow the medication with a large glass of water during meals to prevent contact with the esophageal mucosa (risk of esophageal injury) and not be taken while lying down or before bedtime. This indicates that tube feeding is not recommended.
[MedRec]
[chemotherapy]
All repeat prescriptions from our endocrinologist, orthopedist, and cardiologist were added to the active medication list, with the exception of midorine. During this hospitalization, there is no evidence of symptomatic orthostatic hypotension in the HIS5 records, so no reconciliation issues were identified.
[diagnosis] - 20230114 discharge note
[past history]
[exam findings]
[consultation]
[MedRec]
[radiotherapy]
[chemotherapy]
2023-08-02
2023-07-11
2023-06-23 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg NS 500mL 2hr + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 2800mg 3500mg NS 500mL 46hr (FOLFIRINOX, Iri 90%, 5FU 80%)
2023-05-31 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg NS 500mL 2hr + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 2800mg 4320mg NS 500mL 46hr (FOLFIRINOX)
2023-04-07 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 235mg NS 500mL 2hr + leucovorin 400mg/m2 625mg NS 500mL 2hr + fluorouracil 2800mg 4375mg NS 500mL 46hr (FOLFIRINOX)
2023-03-09 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 235mg NS 500mL 2hr + leucovorin 400mg/m2 625mg NS 500mL 2hr + fluorouracil 2800mg 4385mg NS 500mL 46hr
2023-02-13 - fluorouracil 225mg/m2 340mg NS 500mL 24hr D1-5 (CCRT)
2023-02-06 - fluorouracil 225mg/m2 340mg NS 500mL 24hr D1-5 (CCRT)
All repeat prescriptions issued by our gastroenterologist on 2023-05-17, cardiologist on 2023-06-06, and general surgeon on 2023-07-25 have been consistently refilled. These medications have been added to the active medication list, and no reconciliation issues have been identified.
[MedRec]
[diagnosis]
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
This patient refilled Eurodin (estazolam) and Lexapro (escitalopram) on 2023-07-10 issued by our psychosomatic medicine department and these drugs have been included in the active medication list without a reconciliation issue found.
[fluconazole dosing for HD patients]
For patients undergoing intermittent (thrice weekly) hemodialysis, whether intravenous or oral fluconazole is used, the dosing should be administered three times a week after each dialysis session. No dosage adjustment is required for indication-specific loading/initial or maintenance doses recommended in the adult dosing section. However, it is important to administer maintenance doses only three times per week on dialysis days after the dialysis session.
[lab data]
[exam findings]
[MedRec]
[chemoimmunotherapy]
The patient recently renewed her repeat prescription for Diovan (valsartan) to manage her primary hypertension at a local pharmacy on 2023-07-19. This medication is currently listed in the active formulary, and no reconciliation issues have been identified.
The most recent medical image was scaned on 2023-05-05 (abdomen CT). An update may be beneficial to reassess the current disease status.
[exam findings]
[MedRec]
[medication reconciliation]
The patient was prescribed famotidine, cyanocobalamin, and betamethasone on 2023-07-28 for a 7-day duration at JingMei Hospital to address her malignant neoplasm of the small intestine. However, these medications are currently not included in the active medication list. It is advised to review whether they are still necessary for the patient’s current condition.
[exam findings]
[consultation]
[immunochemotherapy]
On 2023-06-10, our urologist wrote a 3-time refill prescription (valid for 84 days) for Harnalidge (tamsulosin) and Betmiga (mirabegron). Additionally, on 2023-06-12, our cardiac surgeon issued a 3-time repeat prescription (also valid for 84 days) for Blopress (candesartan), Bokey (aspirin), Concor (bisoprolol), Eurodin (estazolam), and Crestor (rosuvastatin). These medications have been included in the active medication list, and no reconciliation issues have been identified.
In accordance with the PharmaCloud database, this patient has only been a patient of our hospital for the last 3 months. In addition to our hemato-oncology department, our urologist prescribed Harnalidge (tamsulosin) and Betmiga (mirabegron) on 2023-06-10. In addition, our cardiac surgeon prescribed Blopress (candesartan), Bokey (aspirin), Concor (bisoprolol), Eurodin (estazolam), and Crestor (rosuvastatin) on 2023-06-12. These medications have been accurately added to the list of active medications and no discrepancies have been identified in the reconciliation.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[reconciliation]
Our hospital is the only medical provider for this patient according to the PharmaCloud database, no medication reconciliation issues identified.
[tube feeding]
Betmiga (mirabegron) is a long acting formulation, it is not recommended to crush or halve for tube feeding. As the effect of mirabegron 50mg is approximately equivalent to that of propiverine 30mg, it is recommended to switch to Urotrol (propiverine 15mg), 1# BID for tube feeding. Doxaben XL (doxazosin) is a sustained-release formulation. It is suggested to consider switching to Urief (silodosin) as an alternative to Doxaben.
[diagnosis] - 2023-04-06 admission note
[past history]
[allergy]
[family history]
There is no family history of cancer, diabetes, hypertension, mental diseases or asthma.
[exam findings]
[consultation]
[chemoimmunotherapy]
Based on the PharmaCloud database, we see that the patient has only visited our hemato-oncology department in the last 3 months. As a result, no medication reconciliation issues are identified for this admission.
[exam findings]
[SOAP]
[surgical operation]
[chemotherapy]
Based on the PharmaCloud database, we see that the patient has only visited our hospital. No medication reconciliation issues are identified for this admission after reviewing HIS5 records..
On 2023-07-26, the serum magnesium level was measured at 1.5mg/dL, indicating a low value. As a result, it is advised to add magnesium supplementation for the patient.
[exam findings]
[MedRec]
[immunochemotherapy]
[reconciliation]
Our dermatologist prescribed a 7-day course of Compesolon (prednisolone), Xyzal (levocetirizine), Asthan (ketotifen), Pilan (cyproheptadine), and Topsym Cream (fluocinonide) for the patient’s severe itchy papules and plaques eruption over the trunk on 2023-07-20. However, these drugs are not currently included in the list of active medications. It is advisable to check whether the skin symptoms have improved before continuing or adjusting the treatment plan.
[lab data]
2023-07-19 HSV 1 IgM Negative NTU
2023-07-19 HSV 1 IgM Value 1.52 NTU
2023-07-19 HSV 2 IgM Negative NTU
2023-07-19 HSV 2 IgM Value 1.37 NTU
2023-07-19 HLA A-high 11:01
2023-07-19 HLA A-high 33:03
2023-07-19 HLA B-high 38:02
2023-07-19 HLA B-high 39:01
2023-07-19 HLA C-high 07:02
2023-07-19 HLA C-high -
2023-07-19 HLA DRB1-high rsolution 2023-07-19 HLA DQ-high 03:03
2023-07-19 HLA DQ-high 05:02
2023-07-19 HLA DRB1-high rsolution 2023-07-19 HLA DR-high 09:01
2023-07-19 HLA DR-high 14:54
[exam findings]
[MedRec]
[chemotherapy]
2023-07-19 - L-asparaginase 6000unit/m2 9540unit IM 1min
2023-07-10 - methotrexate 4600mg NS 250mL 24hr
2021-02-18
2021-01-14
2020-12-21
2020-11-27
2020-11-13
2020-10-06
2020-09-29
[deterioration in liver function; acetaminophen, Stronger Neo Minophagen C Injection]
In recent days, the patient has shown a significant increase in bilirubin and liver enzymes. After reviewing the drugs listed in the active medication, entecavir, furosemide, and acetaminophen are found to be associated with these symptoms according to the medication database. Since the VAS (visual analogue scale) has been recorded as 0 since 2023-07-29, it might be worth considering discontinuing acetaminophen. Additionally, please note that the Stronger Neo Minophagen C Injection will expire by the morning of 2023-08-01. If it is still required, please extend its use accordingly.
2023-07-31 Bilirubin total 14.51 mg/dL ** 2023-07-27 Bilirubin total
2.44 mg/dL *
2023-07-26 Bilirubin total 1.02 mg/dL
2023-07-24 Bilirubin total 0.70 mg/dL
2023-07-21 Bilirubin total 0.49 mg/dL
2023-07-19 Bilirubin total 0.51 mg/dL
2023-07-17 Bilirubin total 0.52 mg/dL
2023-07-15 Bilirubin total 0.59 mg/dL
2023-07-14 Bilirubin total 0.68 mg/dL
2023-06-27 Bilirubin total 0.31 mg/dL
2023-07-31 S-GPT/ALT 655 U/L 2023-07-27 S-GPT/ALT 309 U/L 2023-07-26 S-GPT/ALT 219 U/L 2023-07-24 S-GPT/ALT 161 U/L 2023-07-21 S-GPT/ALT 180 U/L 2023-07-19 S-GPT/ALT 162 U/L 2023-07-17 S-GPT/ALT 278 U/L 2023-07-15 S-GPT/ALT 541 U/L 2023-07-14 S-GPT/ALT 638 U/L 2023-07-13 S-GPT/ALT 412 U/L 2023-07-09 S-GPT/ALT 137 U/L 2023-06-27 S-GPT/ALT 63 U/L 2023-06-23 S-GPT/ALT 62 U/L 2023-06-18 S-GPT/ALT 46 U/L 2023-06-05 S-GPT/ALT 31 U/L 2023-06-03 S-GPT/ALT 26 U/L
[No specific preparation is described for Stronger Neo-Minophagen C Injection]
to primary nurse: After checking the Micromedex database, there is no available data on the compatibility of glycyrrhizinate monoammonium, the main ingredient in Stronger Neo-Minophagen C Injection. Additionally, the package insert for this medication does not provide specific instructions regarding the preparation prior to injection administration.
[teicoplanin 600mg from Q3D to QOD]
2023-07-19 Cre 1.47mg/dL, 57.5kg => CrCl 35mL/min. According to the Sanford Guide, teicoplanin in patients with CrCl 30 to 80, for complicated skin/soft tissue, pneumonia, complicated UTI: 6mg/kg QOD and for bone and joint infections, endocarditis: 12mg/kg QOD. It is recommended to increase the frequency from Q3D to QOD.
[leukopenia]
An episode of leukopenia was observed on 2023-07-19, 9 days after administration of 4600 mg MTX on 2023-07-10. The label for MTX includes a boxed warning regarding potential bone marrow, liver, lung, skin, and kidney toxicity, and patients should be monitored closely for such effects. Given the timing and characteristics of MTX, it cannot be ruled out that the leukopenia episode was due to MTX.
According to NHI reimbursement guidelines, short-acting G-CSF (e.g., filgrastim, lenograstim) may be used for patients with hematologic malignancies receiving intravenous chemotherapy, provided the patient meets this condition.
[MTX level follow-up. Leucovorin might begin 24 hr after the start of MTX]
Methotrexate 4600mg was administered on 2023-07-10, and leucovorin 150mg Q3H has been started since 2023-07-13. Follow-up methotrexate level has shown significant decrease and is now less than 10 umol/L.
It is recommended that rescue treatment following high-dose methotrexate starts with an initial dosage of around 15 mg (~10 mg/m2). This should begin 24 hours after the start of the methotrexate infusion and the treatment should continue Q6H for doses, until the MTX level drops below 0.05 micromolar.
The patient is adequately hydrated with normal saline and the urine is alkalinized with Rolikan (sodium bicarbonate).
[bedside visit]
I visited the patient at around 16:00 today. She mentioned that her throat was a bit sore, which could be due to mucositis. The addition of Nincort Oral Gel (triamcinolone acetonide) might help in relieving her symptoms.
[Covorin demand confirmation]
Today, during the UD (Unit Dose) vehicle preparing, it was discovered that the demand for Covorin (leucovorin 50mg) is 72 amps. At 13:25, I made a call to Dr. Wang QiQi to confirm the chief resident physician’s decision on the medication quantity.
[diagnosis] - 2023-03-13 admission note
[past history]
[family history]
[lab data]
[exam findings]
[consultation]
[MedRec]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
[note]
Chemotherapy regimens for advanced esophagogastric cancer: Docetaxel, cisplatin, and fluorouracil (DCF) 2023-07-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F73324
Chemotherapy regimens for locally advanced, potentially resectable gastric or gastro-esophageal junction adenocarcinoma: Perioperative docetaxel, oxaliplatin, fluorouracil, and leucovorin (FLOT4) 2023-03-14 https://www.uptodate.com/contents/image?imageKey=ONC%2F120512
ref: Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet. 2019;393(10184):1948-1957. doi:10.1016/S0140-6736(18)32557-1
This patient receives all medical care exclusively at our hospital and has appointments with both the hematology-oncology and endocrinology and metabolism departments. Medications prescribed by the endocrinology and metabolism department, including Cardiolol (propranolol), Galvus Met (vildagliptin, metformin), and methimazole, were correctly documented on the active medication list. As a result, no medication reconciliation issues were identified.
[lab data]
2023-07-18 CA-199 (NM) 52.608 U/ml
2023-07-04 CA-199 (NM) 38.491 U/ml
2023-06-09 CA-199 (NM) 39.33 U/ml
2022-05-26 CA-199 53.04 U/mL
2023-06-09 HBsAg (NM) Negative
2023-06-09 HBsAg Value (NM) 0.373
2023-06-09 Anti-HCV (NM) Negative
2023-06-09 Anti-HCV Value (NM) 0.042
2023-06-09 Anti-HBc (NM) Positive
2023-06-09 Anti-HBc Value (NM) 0.009
2023-06-09 Anti-HBs (NM) Negative
2023-06-09 Anti-HBs value (NM) 4.06 mIU/mL
2022-05-26 HBsAg Nonreactive
2022-05-26 HBsAg (Value) 0.63 S/CO
2022-05-26 Anti-HCV Nonreactive
2022-05-26 Anti-HCV Value 0.08 S/CO
[exam findings]
[MedRec]
[consultation]
[medication reconciliation]
This patient just refilled Betmiga (mirabegron) on 2023-07-10 for her urinary incontinence for a 28-day valid duration at Far Eastern Hospital, this drug is not included in the active medication list, please confirm if this drug is not necessary for the patient’s current condition.
[poor medication compliance, non-adherence to medication regimen]
The 2023-07-26 progress note states, “The patient requested to self-administer her medications, adjusting them based on her daily condition. She expressed concern about receiving medications from nurses. The nurse practitioner educated her about the safety of medication administration by the nursing team, but the patient was unable to accept it. As a result, the patient’s outpatient medication was discontinued”.
On 2023-07-26, I visited the patient and her caregiver at approximately 11:00 am to address the concerns raised in the progress note regarding the patient’s medication compliance.
The patient said she is a member of TzuChi and was diagnosed with suspected cholangiocarcinoma in 2022-05 and subsequently treated at ShinKong Hospital. During the visit, I found that the patient tends to be selective in taking prescribed medications, believing that certain medications are more effective and should be taken more, while she perceives little efficacy from other prescribed medications. In addition, the patient mentioned that she does not always take her prescribed painkiller.
I have tried to help the patient understand the importance of adhering to the prescribed medication regimen. However, it appears that the patient still holds strong personal beliefs regarding medication, which may lead to inaccurate assessments of treatment effectiveness.
Regarding the issue of low sodium levels, I advised the patient to increase her salt intake, the patient attributed this to the caregiver’s cooking, as she felt that the meals were not seasoned enough. However, upon further discussion with the nurses, the caregiver mentioned that she already added an adequate amount of salt to the meals.
{not completed}
[exam findings]
[consultation]
[MedRec]
[chemotherapy]
Episodes of anemia were evident according to the most recent lab results.
The most recent chemotherapy administration was initiated on 2023-06-30. Additionally, the patient experienced several GI tumor bleeding events since 2023-03 and received blood transfusions on the following dates: 2023-03-24, 2023-03-25, 2023-04-05, 2023-04-12, 2023-04-19, 2023-04-23, 2023-06-30, 2023-07-07, 2023-07-19, and 2023-07-24. Considering that both tumor bleeding and blood transfusions can affect HGB levels, it is difficult to conclusively attribute anemia solely to chemotherapy, and the potential impact of chemotherapy cannot be completely ruled out.
Studies indicate that patients with gastroenteropancreatic neuroendocrine carcinoma who receive cisplatin/etoposide treatment can have an Objective Response Rate (ORR) ranging from 14% to 67%, as stated in “Systemic Treatment of Gastroenteropancreatic Neuroendocrine Carcinoma. Curr. Treat. Options in Oncol. 22, 68 (2021).”
The CT scan on 2023-07-05 demonstrated stable disease for the neuroendocrine carcinoma of the pancreatic body and tail, following 3 cycles of the cisplatin/etoposide regimen. This might suggest that the disease could be developing some degree of resistance to the treatment.
After reviewing the PharmaCloud database and in-hospital HIS5 records, no medication reconciliation issues were identified.
The patient sought treatment for unspecified dermatitis at Huang ZhenXian Dermatology Clinic on 2023-05-08 and was prescribed tranexamic acid, betamethasone, prednisolone, and loratadine for a short duration of 3 days. Currently, no dermatitis-related symptoms are observed in the admission note or the active medical problem list. Therefore, no medication reconciliation issues are identified.
[exam findings]
[MedRec]
[consulation]
[radiotherapy]
[chemotherapy]
[tube feeding - Concor]
According to the manufacturer’s instructions for Concor (bisoprolol 5 mg tablets), it should be swallowed with a drink of water and not chewed. However, if the patient is receiving tube feeding, the Simple Suspension Method (SSM) can be used. This method involves dissolving the tablets in warm water for 5-10 minutes and then passing the solution through a feeding tube for administration. The Simple Suspension Method may be appropriate for administration of Concor tablets through a feeding tube.
[renal dosing Tapimycin from Q6H to Q8H]
Kidney function appears to be deteriorating in this patient. 2023-07-25 CrCl 27 mL/min.
When using Tapimycin (piperacillin 4g, tazobactam 0.5g) in patients with a CrCl between 20 and 40, if the intended dose is 4.5g Q6H infused over 30 minutes, then the recommended doses are either 4.5g Q8H or 3.375g Q6H, with the former being preferred.
A dose of 4 mg once daily is recommended when using Urief (silodosin 8 mg) in patients with a CrCl between 30 and 50.
[leukopenia and thrombocytopenia]
Bicytopenia (leukopenia and thrombocytopenia) is evident based on recent lab results after consecutive 5-day fluorouracil administration (for CCRT), which started on 2023-06-26 and 2023-07-14.
2023-07-25 WBC 0.16 x10^3/uL
2023-07-14 WBC 2.82 x10^3/uL
2023-07-05 WBC 6.47 x10^3/uL
2023-06-26 WBC 8.28 x10^3/uL
2023-06-13 WBC 9.43 x10^3/uL
2023-07-25 HGB 9.0 g/dL
2023-07-14 HGB 9.1 g/dL
2023-07-05 HGB 9.5 g/dL
2023-06-26 HGB 8.3 g/dL
2023-06-13 HGB 10.0 g/dL
2023-07-25 PLT 80 *10^3/uL
2023-07-14 PLT 301 *10^3/uL
2023-07-05 PLT 299 *10^3/uL
2023-06-26 PLT 340 *10^3/uL
2023-06-13 PLT 459 *10^3/uL
Blood transfusions are performed on 2023-05-27, 2023-06-01, 2023-06-26, 2023-07-14, 2023-07-25 and Granocyte (lenograstim 250ug) is to be administered since 2023-07-25 for consecutive 6 days. No issue with the use of G-CSF.
[ARBs Equivalent Dose Conversion]
This patient is currently self-administering Diovan (valsartan 40mg) once daily and the supply is almost exhausted. Upon checking, our hospital only carries a 160mg dosage, which is inconvenient to divide into quarters. However, Olmetec (olmesartan 20mg) or Blopress (candesartan 8mg) is an option, as it belongs to the class of angiotensin II receptor blockers (ARBs) just like valsartan. Considering that approximately 40 mg of valsartan is equivalent to 10 mg of olmesartan or 4 mg of candesartan, it may be advisable to prescribe Olmetec at a dose of 0.5 tablets or Blopress at a dose of 0.5 tablets per day as a suitable alternative.
Our dermatologist prescribed fusidic acid and doxycycline on 2023-07-04 and these drugs are integrated into the active medication list without reconciliation issues found
[to replace Forxiga with Jardiance]
[patient education: 5-FU]
[reconciliation]
[MedRec]
This patient has been regularly visiting multiple departments at our hospital and receiving several repeat prescriptions.
Cardiology prescribed the following medications: - Norvasc (amlodipine) - Syntrend (carvedilol) - Meletin (mexiletine) - Ulstop (famotidine) - Plavix (clopidogrel) - Urief (silodosin)
Endocrinology prescribed the following medications: - NovoRapid (recombinant insulin aspart) - Toujeo (insulin glargine) - Kentamin (vitamin B1, B6, B12) - Lipanthyl (fenofibrate) - Through (sennoside) - Tulip (atorvastatin)
Neurology prescribed the following medications: - Dipydidamole - Sketa (acetaminophen, chlorzoxazone) - Rivotril (clonazepam) - Neurontin (gabapentin)
Ophthalmology prescribed the following eye medications: - Combigan Eye Drops (brimonidine, timolol) - Vidisic Gel (carbomer) - Tears Naturale (hydroxypropyl methylcellulose, dextran 70)
All the oral drugs have been included in the active medication list, except for the eye medications. Please check if the patient still needs these eye medications.
[exam findings]
[chemotherapy]
[exam findings]
[chemoimmunotherapy]
atezolizumab 2023-05-15 https://www.uptodate.com/contents/atezolizumab-drug-information
Brand Names: Tecentriq
Pharmacologic Category
Dosing: Adult
[De-escalation of Cefepime]
Based on in-hospital stock, the only available third-generation oral cephalosporin is Ceficin (cefixime 100mg) at a recommended dosing frequency of 2# Q12H. As the patient’s laboratory data on 2023-07-24 showed normal values for creatinine and blood urea nitrogen (BUN), there is no need to adjust the dosage of Ceficin.
[diagnosis] - 2023-04-12 admission note
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[note]
TPF regimens for Neoadjuvant Chemotherapy (in-hospital Chemotherapy Regimens for Head and Neck Cancer: Collection as of 2022-02-11) - see No.701240721, with docetaxel 40mg/m2 and cisplatin 40mg/m2
Docetaxel, cisplatin and fluorouracil induction chemotherapy followed by chemoradiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX324) 2023-04-13 https://www.uptodate.com/contents/image?imageKey=ONC%2F65438
Cycle length: Every 21 days for three cycles.
Regimen
In search for optimal induction chemotherapy for advanced nasopharyngeal cancer: Standard dosing of Docetaxel, Platinum, and 5-Fluorouracil (TPF) followed by chemoradiation. Published: 2023-02-02. https://doi.org/10.1371/journal.pone.0276651
[duplicated H2RA]
The concomitant use of histamine H2-receptor antagonists such as Stogamet (cimetidine 300mg) and Ulstop (famotidine 20mg) is generally not recommended. Both drugs work by reducing the production of stomach acid, and using them together may increase the risk of side effects. It is advisable to evaluate the need to use these two drugs together to ensure drug safety.
[diagnosis] - 2023-04-06 admission note
Malignant neoplasm of unspecified site of unspecified female breast
2023-03-17 discharged note
[past history] - 2023-03-15 admission note
[allergy]
[family history]
[exam findings]
[chemotherapy]
According to the PharmaCloud database, it appears that the patient has only been receiving medical care at our hospital for the past three months. No medication reconciliation issues were identified during her current admission.
Recently, a noticeable increase in ALT, AST and bilirubin levels can be seen based on the weekly lab data.
2023-07-12 S-GPT/ALT 119 U/L
2023-07-05 S-GPT/ALT 129 U/L
2023-06-28 S-GPT/ALT 132 U/L
2023-06-21 S-GPT/ALT 145 U/L
2023-06-14 S-GPT/ALT 112 U/L
2023-06-07 S-GPT/ALT 53 U/L
2023-07-12 S-GOT/AST 431 U/L
2023-07-05 S-GOT/AST 279 U/L
2023-06-28 S-GOT/AST 180 U/L
2023-06-21 S-GOT/AST 169 U/L
2023-06-14 S-GOT/AST 115 U/L
2023-06-07 S-GOT/AST 66 U/L
2023-07-12 Bilirubin total 2.73 mg/dL
2023-07-05 Bilirubin total 1.90 mg/dL
2023-06-28 Bilirubin total 1.00 mg/dL
2023-06-21 Bilirubin total 0.56 mg/dL
2023-06-14 Bilirubin total 0.40 mg/dL
2023-06-07 Bilirubin total 0.34 mg/dL
Per UpToDate, Enhertu (trastuzumab deruxtecan) is linked to a raised serum alanine aminotransferase (34% to 53%), elevated serum alkaline phosphatase (22% to 54%), increased serum aspartate aminotransferase (35% to 67%), and elevated serum bilirubin (16% to 24%).
According to the Enhertu label, there are limited data available for patients with moderate hepatic impairment, and none for patients with severe hepatic impairment. Given that metabolism and biliary excretion are the primary elimination routes for the topoisomerase I inhibitor component (DXd) in Enhertu, caution should be exercised when administering Enhertu to patients with moderate or severe hepatic impairment. The package insert does not provide dose adjustment guidelines based on LFT readings. It might be suggested to temporarily withhold the drug until the drug is ruled out as the cause of deterioration of liver function.
[diagnosis] - 20230103 admission note
[present illness] - 20230103 admission note
[past history]
[Allergy]
[family history]
[lab data]
[exam findings]
[MedRec]
[consultation]
[chemoimmunotherapy]
Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in medically-fit patients - 20230104 https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients
2023-07-16 (D9) WBC level has risen to 1.64K/uL, the recovery is obvious and the CMV viral load test showed that no virus was detected on 2017-07-17 (today). So far so good.
After the transplant, the patient’s kidney function levels fluctuate up and down around the upper limits of the normal range. A slight elevation in serum Cre is observed on 2023-07-13 and is to be followed.
The LFT results showed a monotonic increase in bilirubin levels after the transplant, as the enzyme levels started to fall, it might be sufficient to observe for a short time, if bilirubin still remains high, then action might need to be taken. Mycamine (micafungin) is associated with hyperbilirubinemia (UpToDate: <15%).
[liver function]
It seems that the patient’s liver function has declined, as indicated by increased levels of ALT, AST, and bilirubin.
2023-07-09 S-GPT/ALT 174 U/L
2023-07-03 S-GPT/ALT 71 U/L
2023-06-25 S-GPT/ALT 50 U/L
2023-06-09 S-GPT/ALT 38 U/L
2023-06-02 S-GPT/ALT 29 U/L
2023-05-25 S-GPT/ALT 27 U/L
2023-07-09 S-GOT/AST 101 U/L
2023-07-03 S-GOT/AST 43 U/L
2023-06-25 S-GOT/AST 40 U/L
2023-06-09 S-GOT/AST 29 U/L
2023-06-02 S-GOT/AST 22 U/L
2023-07-09 Bilirubin direct 0.43 mg/dL
2023-07-03 Bilirubin direct 0.16 mg/dL
2023-06-25 Bilirubin direct 0.13 mg/dL
2023-07-09 Bilirubin total 1.34 mg/dL
2023-07-03 Bilirubin total 0.63 mg/dL
There are several drugs on the patient’s active list that could potentially contribute to the decline in liver function. These include:
Given that another anti-HBV drug Baraclude (entecavir) can also lead to increased serum alanine aminotransferase levels (>5 x ULN: 11% to 12%; >10 x ULN and >2 x baseline: 2%), substituting tenofovir alafenamide with entecavir is not advised at present time. Similarly, another antifungal medication micafungin can lead to an increased serum alkaline phosphatase level (3% to 6%).
Considering the recent dosage increase of BaoGan (silymarin) on 2023-07-09 from 1# TID to 2# TID, rechecking the liver function tests in 2 days could be a practical strategy.
[renal function]
Aside from a slightly elevated BUN, decreasing serum creatinine and increasing eGFR suggest an improvement in the patient’s renal function. The CrCl has increased to 44 mL/min.
2023-07-09 Creatinine 1.22 mg/dL
2023-07-03 Creatinine 1.40 mg/dL
2023-06-25 Creatinine 1.76 mg/dL
2023-07-09 eGFR 61.38
2023-07-03 eGFR 52.37
2023-06-25 eGFR 40.21
2023-07-09 BUN 26 mg/dL
2023-07-03 BUN 28 mg/dL
2023-06-25 BUN 25 mg/dL
If the CrCl remains above 50 mL/min stably for several days and no further decline is expected, the dose of levofloxacin could optionally be increased to 750mg daily. In addition, the fluconazole dose could optionally be increased to 2# QD once it has been determined that it is not the cause of the deterioration in liver function.
[myeloablative conditioning regimen effect follow-up]
The BuCyE regimen was initiated on 2023-06-30, and there is a notable reduction in WBC, HGB, and PLT levels, which indicates that the regimen is taking effect.
2023-07-07 WBC 0.71 x10^3/uL
2023-07-05 WBC 3.07 x10^3/uL
2023-07-03 WBC 3.46 x10^3/uL
2023-06-25 WBC 5.39 x10^3/uL
2023-07-07 HGB 9.3 g/dL
2023-07-05 HGB 11.6 g/dL
2023-07-03 HGB 12.1 g/dL
2023-07-07 PLT 33 x10^3/uL
2023-07-05 PLT 67 x10^3/uL
2023-07-03 PLT 80 x10^3/uL
[renal function follow-up]
[dosage reviewed for current renal function level]
[pharmacist shift handover to chemotherapy preparation room]
Stem Cell Infustion Date D0: 2023-07-07 (tentative)
Drug - Dose - Infusion - Frequency - Duration - Date busulfan - 3.2mg/kg - 3hr - QD - D-7 ~ D-5 - 2023-06-30 ~ 2023-07-02 etoposide - 400mg/m2 - 6hr - QD - D-5 ~ D-4 - 2023-07-02 ~ 2023-07-03 cyclophosphamide - 50mg/m2 - 4hr - QD - D-3 ~ D-2 - 2023-07-04 ~ 2023-07-05
[Recommended Dose Adjustments for the BuCyE Conditioning Regimen and Associated Premedication]
2023-06-25 serum Cre 1.76mg/dL, age 76 => CrCl 30mL/min; height 162cm, weight 60kg => BMI 22.9kg/m2, BSA 1.64m2; 2023-06-25 S-GPT/ALT 50U/L, S-GOT/AST 40U/L, DBI/TBI 18.31%.
For BuCyE conditioning regimen, dose adjustment recommendation for the scheduled ASCT in this impaired renal function patient
For premedication
[Preparation and Administration of Mesna]
[past history]
[lab data]
2023-06-28 HIV Ab-EIA Nonreactive
2023-06-28 Anti-HIV Value 0.09 S/CO
2023-06-26 MTBC PCR DETECTED CFU/ml
2023-06-26 MTBC PCR Value 10000 - 100000 CFU/ml
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[tube feeding]
For patients on tube feeding, Dexilant (dexlansoprazole 60mg/cap) can be administered by breaking the capsule open and pouring the small granules into an appropriate amount of drinking water. After mixing well, this prepared solution can be administered through the feeding tube. Note that these granules should not be crushed or chewed, and the prepared solution should be used immediately after it’s prepared.
[reconciliation]
According to the PharmaCloud database, it appears that the patient has only been receiving medical care at our hospital for the past three months. No discrepancies or issues were identified during the medication reconciliation process for this patient during his current admission.
[assessment]
It appears that the patient’s renal function deteriorated last weekend. 2023-07-15 CXR showed ground-glass opacities in both lungs. CRP 13.8 mg/dL. There is a high incidence of AKI in patients hospitalized for CAP. It is advisable to be alert for the prevention and early detection of AKI in CAP patients. ref: Incidence and Risk Factors of Acute Kidney Injury in Patients Hospitalized with Pneumonia: A Prospective Observational Study. Med J Islam Repub Iran. 2021;35:150. Published 2021 Nov 10. doi:10.47176/mjiri.35.150
2023-07-15 Creatinine 1.76 mg/dL
2023-07-06 Creatinine 1.08 mg/dL
2023-07-03 Creatinine 1.05 mg/dL
2023-07-15 eGFR 43.10
2023-07-06 eGFR 75.73
2023-07-03 eGFR 78.23
The current dosage of Tapimycin (peperacillin 4g, tazobactam 0.5g) at 4.5g Q8H is still within a reasonable range, considering the patient’s current renal function.
In patients who are on tube feeding, Dexilant (dexlansoprazole 60mg/cap) can be administered by breaking open the capsule and pouring the tiny granules into an appropriate amount of drinking water. After mixing well, this prepared solution can be delivered via the feeding tube. Do bear in mind that these granules shouldn’t be crushed or chewed, and the prepared solution must be used right after its preparation.
From 2023-03-28 to 2023-06-16, the patient has experienced significant weight loss, dropping from 53.1kg to 41.6kg. This indicates a loss of over 10kg within a span of approximately 2.5 months. A consultation with a dietitian took place on 2023-05-19. However, cachexia remains a current health issue for this patient. The patient is currently on tube feeding and is also taking the progesterone analogue megestrol without an issue. Glucocorticoids could potentially improve the patient’s appetite to a similar extent as the progesterone analogues. However, considering the potential for toxicities and decreased effectiveness with prolonged use, the application of glucocorticoids as an appetite stimulant is typically reserved for individuals with an estimated life expectancy ranging from a few weeks to a couple of months. Consequently, the use of glucocorticoids is not advised at this time.
The patient’s renal function markers continue to be elevated, so hydration has been administered (NS 500mL Q8H currently). The TPR panel reveals that the patient was experiencing tachycardia (122/min), tachypnea (21/min), and potentially inadequate SpO2 (92%), alongside a relatively low blood pressure reading (81/52 mmHg). Close monitoring is necessary in this case.
[tube feeding]
[exam findings]
[MedRec]
2023-04-26 ~ 2023-04-29 POMR Neurosurgery
2023-04-18 SOAP Hemato-Oncology
2023-04-11 ~ 2023-04-14 POMR Metabolism and Endocrinology (not completed)
2023-02-15 SOAP Hemato-Oncology
2022-12-20 SOAP Hemato-Oncology
[surgical operation]
[chemotherapy]
2023-07-03 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor)
2023-05-23 - FOLFOX @ Thailand
2023-05-09 - FOLFOX @ Thailand
2023-04-25 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)
2023-03-28 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)
2023-03-14 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)
2023-03-01 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)
2023-02-15 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)
2023-01-30 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX Q2W)
2023-01-16 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX Q2W)
[reconciliation]
The patient is not from the local area, so no records are available in the PharmaCloud database.
On 2023-05-03, our endocrinologist prescribed Canaglu (canagliflozin), Trajenta (linagliptin), Uformin (metformin), and Kludone (gliclazide). On the same day, our neurosurgeon prescribed Keppra (levetiracetam), Neurontin (gabapentin), Norvasc (amlodipine), and Tulip (atorvastatin). These prescriptions, which are valid for 70 days, were added to the patient’s current medication list with no discrepancies identified during medication reconciliation.
[assessment]
A recent lab reading taken on 2023-07-11 revealed a significantly elevated serum glucose level of 253mg/dL, despite the administration of four antiglucemic agents - Canaglu (canagliflozin), Trajenta (linagliptin), Uformin (metformin), and Kludone (gliclazide). It would be advisable to ensure regular monitoring of the patient’s blood sugar levels, and these readings should be displayed in the TPR panel.
[reconciliation]
[bedside visit, patient education]
[exam findings]
[consultation]
[chemotherapy]
G-CSF (filgrastim) 150ug
WBC
After reviewing the PharmaCloud database, no reconciliation issues were found.
[exploring CNS involvement]
An increased level of LDH is more common seen in patients with AML involving the CNS. Given that this patient was admitted with symptoms of dizziness and tinnitus, it could be worthwhile to conduct further investigations.
[exam findings]
[consultation]
[chemotherapy]
[exam findings]
[MedRec]
[consultation]
[chemoimmunotherapy]
Granocyte (lenograstim) 250mg SC
lab WBC
[note]
It appears that the approximate cycled trough WBC count occured around one week after the administration of single bleomycin agent, the G-CSF administration might follow this pattern.
The AFP/beta-HCG/LDH tests might be conducted again in December 2022 to make the monitor frequency not fall below two months. (There were still superior mediastinal widening and an enlarged Lt hilum on the CXR of 2022-11-30)
Pulmonary fibrosis is the most severe toxicity associated with bleomycin. The most frequent presentation is pneumonitis occasionally progressing to pulmonary fibrosis. Its occurrence is higher in elderly patients and in those receiving more than 400mg total dose, but pulmonary toxicity has been observed in young patients and those treated with low doses.
The primary chemotherapy regimen for germ cell tumors could be BEP, which consists of the following components (NCCN).
AST, ALT, Cre, and eGFR (2022-10-19) did not exhibit abnormalities, therefore no dose adjustment would be required for the BEP regimen based on pharmacokinetics.
The dose used is slightly lower than that recommended by the NCCN (currently: 80mg/m2 of etoposide, 15mg/m2 of cisplatin. NCCN: 100mg/m2, 20mg/m2). Given that the patient’s performance status scale is ECOG 0, it might be an option to upgrade the dose to meet the guideline to obtain more expected effects if no other considerations exist.
(not completed)
[exam findings]
[chemotherapy]
[reconciliation]
This patient intermittently visits a local ophthalmology clinic due to symptoms in his left eye. His most recent visit was on 2023-06-30, and the prescription given, which was valid for 3 days, has now expired. Please decide whether to refer him to our hospital’s ophthalmology department based on his current clinical condition.
[MedRec]
Recent lab data
Elevated serum glucose. This patient has type 2 DM and CVD, SGLT2i might be a choice to protect heart while lowering blood sugar.
SGLT2i such as empagliflozin, dapagliflozin, canagliflozin are available in stock could be prescirbed if UTI is unlikely.
{not completed}
[diagnosis] - 2023-05-08 admission note
[exam findings]
[consultation]
[surgical operation]
[chemoimmunotherapy]
According to the PharmaCloud database, this patient only receives medical services at our hospital. Cross-referencing this with HIS5 records, there were no active prescriptions issued by other departments. Consequently, no medication reconciliation issues were identified.
Granocyte (lenograstim) is pre-prescribed for 2 to 3 consecutive days, a few days after each chemotherapy session, as a prophylactic measure against leukopenia. Since mid-Nov 2021, the patient’s WBC count has remained consistently above 3K/uL.
[chemotherapy]
[exam findings]
[consultation]
[radiotherapy]
[chemotherapy]
The patient previously visited WanFang Hospital on 2023-06-02 for treatment of hemorrhoids and was given a 14-day supply of medication, which has now expired. As the patient did not report any problems related to his hemorrhoids at the time of his current admission, no concerns were identified during the medication reconciliation process.
Continuing from the previous pharmacist note, confirm that Baraclude (entecavir 0.5 mg) 1# QDAC has been prescribed. There are no other medication-related problems at this time.
Lab 2023-06-16 Anti-HBc positive. If immunosuppressive chemotherapy is to be used, it is advisable to use either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD as a precaution, at least during the course of chemotherapy. This would help protect against the potential reactivation of HBV infection by chemotherapy.
[exam findings]
[consultation]
[chemotherapy]
This patient just refilled a prescription for Harnalidge (tamsulosin) on 2023-07-06 for his benign prostatic hyperplasia with lower urinary tract symptoms. This drug has been included in the active medication list with no reconciliation issues identified.
[exam findings]
[MedRec]
[chemotherapy]
Our otorhinolaryngologist prescribed a regimen on 2023-07-05 that included Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), Shitan (bromhexine), Acetal (acetaminophen), Ulstop (famotidine), and Nincort Oral Gel (triamcinolone). Additionally, our endocrinologist provided prescriptions for Crestor (rosuvastatin), Diovan (valsartan), Suwell (aluminum hydroxide, magnesium hydroxide, simethicone), Bokey (aspirin), Norvasc (amlodipine), and Lipanthyl (fenofibrate) on 2023-06-29. All these medications are currently present on the patient’s active medication list, with no detected issues relating to medication reconciliation.
Our otorhinolaryngologist issued a prescription on 2023-06-07, which included Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), Broen-C (bromelain, L-cysteine), Tramacet (tramadol, acetaminophen), and Nincort Oral Gel (triamcinolone) to address the patient’s ENT symptoms. The prescription was given a 14-day duration and is currently still valid. However, none of these drugs appear on the active medication list. Please verify if the related symptoms have resolved, which would explain the absence of these medications from the active list. Thank you!
Laboratory data show that the patient experienced an episode of leukopenia with a WBC count of 2.39K/uL on 2023-05-24, one week after starting his 1st dose of the current treatment regimen on 2023-05-17. Granocyte (lenograstim 250ug) was administered for 3 consecutive days (from 2023-05-24 to 2023-05-26) to increase the WBC count. The 2nd administration of the regimen began on 2023-06-12, maintaining the same dose level as the first cycle. Therefore, a similar incidence of leukopenia might be expected and prophylactic use of G-CSF may be considered to mitigate this potential risk.
{Recurrent hepatocellular carcinoma with lung metastasis, rycT3N0M1, stage IVB}
[diagnosis] - 2022-11-19 admission note
[past history] - 2022-11-19 admission note
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[embolization]
[chemoimmunotherapy]
[note]
Chemotherapy for advanced or metastatic disease treatment regimen listed in in-hospital “Revised Edition of Chemotherapy Prescription Collection for Liver Cancer” version 2022-03-01
Principles of Systemic Therapy - NCCN Clinical Practice Guidelines in Oncology - Hepatocellular Carcinoma - Version 1.2023 - 2023-03-10 - HCC-G 1 of 2, p23
Nivolumab: Drug information 2023-03-02 https://www.uptodate.com/contents/nivolumab-drug-information
Regorafenib: Drug information 2023-03-02 https://www.uptodate.com/contents/regorafenib-drug-information
Our gastroenterologist prescribed a multiple refill prescription for Baraclude (entecavir) on 2023-06-26, which the patient is using for prophylaxis of his HBV reactivation. This medication is included in the patient’s active medication list as a patient-carried item and no reconciliation issue has been identified.
This patient relies only on our hospital for his medical need on liver cell carcinoma, no other healthcare providers found in the PharmaCloud database, no medication reconciliation issues identified.
The dosage of FOLFOX4 administered to this patient during this current treatment cycle has been adjusted in accordance with our in-hospital guidelines outlined in the “Revised Edition of Chemotherapy Prescription Collection for Liver Cancer, version 2023-03-01.” No issues have been identified with this adjustment.
The lab data show a fluctuation in the tumor marker AFP levels, which initially decreased (2022 Q2 to Q3), troughed around 2022 Q3/Q4, and then increased after 2022Q4. This pattern suggests that the “nivolumab + FOLFOX4” regimen, administered monthly since 2022-06, might have become less effective after approximately a year of treatment, indicating potential disease resistance.
This patient has previously been treated with sorafenib (from 2017-10 to 2018-01), regorafenib (from 2021-12 to 2022-08), and nivolumab (since 2021-10). If the disease is confirmed to have developed resistance to these treatments, then potential next-line therapy options could include cabozantinib or lenvatinib.
According to the current version (2023-05-23) NHI medication reimbursement rules, for advanced hepatocellular carcinoma, patients can only choose to use either sorafenib or lenvatinib, but they cannot switch between the two. Additionally, cabozantinib is only covered for patients with intermediate or high-risk advanced renal cell carcinoma who have not previously undergone treatment. Thus, in this patient’s case, it appears cabozantinib or lenvatinib may not be covered based on these regulations.
Currently, Tecopin (teicoplanin 200mg/vial) is out of stock and has been replaced with Targocid (teicoplanin 200mg/vial). If the teicoplanin treatment should continue, please prescribe Targocid.
A multicenter phase II trial (RENOBATE) demonstrated that regorafenib plus nivolumab as first-line therapy for unresectable hepatocellular carcinoma shows promising efficacy outcomes without unexpected safety signals. (ref: Regorafenib plus nivolumab as first-line therapy for unresectable hepatocellular carcinoma (uHCC): Multicenter phase 2 trial (RENOBATE). Changhoon Yoo, etc. Journal of Clinical Oncology 2022 40:4_suppl, 415-415. https://ascopubs.org/doi/abs/10.1200/JCO.2022.40.4_suppl.415 )
Since the end of 2021, Stivarga (regorafenib 40mg/tab) has been prescribed. It is administered at 160mg once daily (4# QD) for the first 21 days of a 28-day cycle. Hand-foot skin reaction has been observed.
[lab data]
2023-04-07 Anti-HBc Reactive
2023-04-07 Anti-HBc-Value 6.97 S/CO
2023-04-07 Anti-HBs 49.82 mIU/mL
2023-04-07 SCC 1.9 ng/mL
2023-04-07 CEA 0.82 ng/mL
2023-03-29 RPR/VDRL Nonreactive
2023-03-29 HBsAg Nonreactive
2023-03-29 HBsAg (Value) 0.44 S/CO
2023-03-29 Anti-HCV Nonreactive
2023-03-29 Anti-HCV Value 0.09 S/CO
2023-03-29 HIV Ab-EIA Nonreactive
2023-03-29 Anti-HIV Value 0.06 S/CO
[exam findings]
[consultation]
[MedRec]
[chemotherapy]
TPF regimen in in-hospital “Prescription Collection of Chemotherapy for Head and Neck Cancer” protocol (dated 2023-03-31)
Docetaxel, cisplatin, and fluorouracil induction chemotherapy followed by radiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX323) 2023-06-12 https://www.uptodate.com/contents/image?imageKey=ONC%2F72461&topicKey=ONC%2F85694
Cycle length: Every 21 days for 4 cycles.
Regimen
Docetaxel, cisplatin and fluorouracil induction chemotherapy followed by chemoradiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX324) 2023-06-12 https://www.uptodate.com/contents/image?imageKey=ONC%2F65438&topicKey=ONC%2F85694
Cycle length: Every 21 days for 3 cycles.
Regimen
[reconciliation]
According to the PharmaCloud database, the patient only receives medical services from our hospital. Therefore, there are no identified medication reconciliation issues.
After examining the PharmaCloud medical records, it’s evident that this patient has been solely receiving care from our hospital over the past three months. All prescriptions have been issued by our outpatient and inpatient hemato-oncology services. Consequently, no medication reconciliation issues have been identified.
The docetaxel/cisplatin/fluorouracil regimen was administered to the patient on 2023-04-24 and 2023-06-09. Historical lab data showed a drop in WBC count below 1000/uL from 2023-05-01 to 2023-05-05, indicating leukopenia roughly 1 to 2 weeks after the initial round of the regimen. A total of 6 doses of Granocyte (lenograstim 250ug) were administered daily between 2023-05-01 and 2023-05-07. Given that the seconnd round of the regimen started on 2023-06-09 with the same dosage as the first, it is plausible that another leukopenia episode could occur about one week after treatment. Therefore, a prophylactic administration of G-CSF post-chemotherapy might be considered.
{metastatic renal cell carcinoma} (not completed)
[history]
[exam findings]
[MedRec]
[immunotherapy]
2023-07-10 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-06-13 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-05-12 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-04-14 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-03-24 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-02-24 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2022-04-22 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-03-28 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-03-01 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2022-02-09 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2022-01-18 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2021-12-28 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2021-11-30 - pembrolizumab 200mg NS 100mL 1hr
2021-11-05 - pembrolizumab 200mg NS 100mL 1hr
2021-10-15 - pembrolizumab 200mg NS 100mL 1hr
2021-09-08 - pembrolizumab 200mg NS 100mL 1hr
2020-10 erlotinib + bevacizumab followed with nivolumab + carboplatin.
[availability of entrectinib and/or alectinib]
According to the latest National Health Insurance (NHI) Drug Reimbursement Guidelines (version dated 2023-05-23), Rozlytrek (entrectinib) is only covered when used alone in adults with ROS-1 positive locally advanced or metastatic NSCLC. Alecensa (alectinib) is covered only for first-line treatment of ALK-positive advanced NSCLC. Both are not covered for papillary renal cell carcinoma.
Both Rozlytrek (entrectinib 200mg/capsule) and Alecensa (alectinib 150mg/capsule) are available in the hospital’s inventory, so no prior authorization is required (no temporary purchase procedure is necessary). The out-of-pocket cost for the former is 1802.5 TWD (NHI price 1530 TWD) and for the latter 487.5 TWD (NHI price 390 TWD).
{autologous Peripheral Blood Stem Cell Transplantation}
chemotherapy with Mabthera on 12/27,Etoposide 500mg/m2 total given 963mg Q12H on 12/28-30 followed by PBSC harvest,GCSF 300mcg QD on 12/31-1/14.Port-A removal on 2022/1/14.
[chemoimmunotherapy]
2023-07-07 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)
2023-05-30 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)
2023-05-08 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)
2023-04-17 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)
2022-08-17 - busulfan 3.2mg/kg 260mg 2hr D1-3 + etoposide 400mg/m2 567mg 1hr D3-4 + cyclophosphamide 50mg/kg 4000mg D5-6 (BuCyE)
2021-12-27 - rituximab 375mg/m2 720mg 8hr D1 + etoposide 500mg/m2 963mg 4hr D2-4
2021-11-19 - etoposide 100mg/m2 190mg 2hr D1-3 + carboplatin AUC5 350mg 24hr D2 + ifosfamide 5000mg/m2 9400mg 24hr D2 + mesna 5000mg/m2 9400mg with ifosfamide (ICE) followed by PBSC harvest, GCSF 300mcg QD on 2021-12-31 ~ 2022-01-14.
2021-10-27 - etoposide 100mg/m2 190mg 2hr D1-3 + carboplatin AUC5 350mg 24hr D2 + ifosfamide 5000mg/m2 9400mg 24hr D2 + mesna 5000mg/m2 9400mg with ifosfamide (ICE)
2021-10-06 - etoposide 100mg/m2 190mg 2hr D1-3 + carboplatin AUC5 350mg 24hr D2 + ifosfamide 5000mg/m2 9400mg 24hr D2 + mesna 5000mg/m2 9400mg with ifosfamide (ICE)
2019-04-03 ~ 2019-09-07 - ESHAP 7 cycles
2017-12-30 ~ 2018-06-01 - ABVD
The patient underwent an autoPBSCT procedure in August 2022, almost a year ago. Based on the Guidelines for Vaccination of Adult BMT Patients provided by Stanford Healthcare, the proposed vaccination schedule is as follows (ref: https://med.stanford.edu/content/dam/sm/bugsanddrugs/documents/clinicalpathways/SHC-Vaccination-BMT.pdf):
According to the guideline, most vaccinations are started 12 months after transplant, so it may be an appropriate time to start planning the vaccination schedule for this patient. This can help reduce the risk of infection and promote the patient’s overall health and recovery.
[preparation and administration of mesna]
[Teicoplanin Dose]
[diagnosis] - 2023-03-09 admission note
[past history] - 2023-03-09 admission note
[allergy]
[family history]
[exam findings]
[MedRec]
[surgical operation]
[immunochemotherapy]
[reconciliation]
[optionally increase Norvasc to 1# daily]
According to PharmaCloud, this patient visited a local clinic for heartburn on 2023-05-03. However, the prescribed medication for a duration of 3 days is now expired. Currently, no issues with medication reconciliation have been identified.
Aside from anemia, the laboratory results from 2023-05-31 were largely within normal limits. There appears to be a downward trend in HGB levels in this patient following the initiation of FOLFOX treatments on 2023-03-09, with hemoglobin levels not fully recovering. This trend warrants continued monitoring.
{Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC}
[lab data]
[exam findings]
[consultation]
[surgical operation]
[chemoimmunotherapy]
2023-06-12 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRINOX, no 5-FU bolus, reduced Oxa)
2023-05-17 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRINOX, no 5-FU bolus for 20230515 WBC 2.9K)
2023-04-24 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRINOX)
2023-03-31 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRINOX) (20230419 WBC 2.27K)
2023-02-21 - oxaliplatin 65mg/m2 114mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2023-02-07 - oxaliplatin 65mg/m2 114mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2023-01-17 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2022-12-29 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2022-12-12 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2022-11-28 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2022-11-10 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2022-10-24 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2022-10-06 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
2022-09-16 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)
2022-08-30 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)
2022-08-15 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)
2022-08-01 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)
2022-07-15 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)
2022-06-30 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)
2022-06-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)
2022-05-25 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)
2022-05-04 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)
2022-04-19 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)
2022-03-30 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)
2022-03-14 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)
2022-02-24 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)
2022-02-11 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)
2022-01-24 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)
2022-01-03 - irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)
2021-12-20 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 400mg/m2 690mg 10min + fluorouracil 2400mg/m2 4100mg 46hr (FOLFIRI, Q2W)
2021-11-23 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 400mg/m2 690mg 10min + fluorouracil 2400mg/m2 4100mg 46hr (FOLFIRI, Q2W)
2021-11-10 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 400mg/m2 690mg 10min + fluorouracil 2400mg/m2 4100mg 46hr (FOLFIRI, Q2W)
2021-10-22 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)
2021-10-07 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)
2021-09-14 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)
2021-09-01 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)
2021-08-19 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)
2021-08-04 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)
2021-07-16 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFOX, Q2W)
2021-07-02 - oxaliplatin 85mg/m2 130mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 3900mg 46hr (FOLFOX, Q2W)
Based on the PharmaCloud database, it’s evident that this patient has been receiving outpatient and inpatient medical services exclusively at our hospital for the past three months. As per the records, our Cardiologist prescribed a refillable order of Concor (bisoprolol), Doxaben (doxazosin), Forxiga (dapagliflozin), Hyzaar (losartan, hydrochlorothiazide), Pravafen (pravastatin, fenofibrate), and Zandip (lercanidipine) on 2023-04-12. These medications are accurately reflected in the patient’s active medication list. Consequently, no medication reconciliation issues have been identified.
Lab data showed a worsening liver function. The patient is currently prescribed OxyNorm (oxycodone 5mg). The package insert for OxyNorm indicates that plasma concentrations may increase in patients with mild to moderate renal impairment and mild hepatic impairment. Therefore, a conservative approach should be taken when adjusting the dosage. For patients with hepatic impairment, the starting dose should be one third to half of the usual initial dose, followed by careful dose adjustment. It is worth noting that 10 mg oral oxycodone is equivalent to 20 mg oral morphine. There is no evidence to suggest that the current dosage of 5mg Q6H is inappropriate. However, close monitoring for potential adverse reactions is recommended.
The most recent lab data (2023-05-16) shows a direct bilirubin level of 0.26mg/dL and an AST level of 45U/L, both slightly exceeding the upper limit of normal. This could indicate potential liver insufficiency. Since fentanyl is primarily metabolized into inactive metabolites in the liver, hepatic insufficiency could potentially slow its elimination. Therefore, patients with impaired liver function using the fentanyl transdermal patch should be monitored for signs of toxicity, and the dose might need to be reduced if necessary. Please update the patient’s liver function readings. If mild to moderate hepatic impairment is confirmed, then the dose is adviced to be reduced by 50%. It’s not recommended to use the fentanyl patch in patients with severe hepatic impairment.
The patient was treated with FOLFIRI from 2021-08 to 2022-09, then with FOLFOX from 2022-10 to 2023-02, and then with FOLFIRINOX since 2023-03. However, due to the obvious upward trend of tumor markers, it is possible that the disease may have developed further resistance to these changed regimens.
The current FOLFIRINOX regimen is being administered without a bolus of 5-FU and with a reduced dose of oxaliplatin, due to observed adverse events and/or patient’s performance status. This is considered an appropriate adjustment and there are no issues identified with this approach.
After image studies in early Oct 2022 revealed a number of lesions with a mild increase in size, and multiple bone metastases in progress, the regimen was changed from FOLFIRI to FOLFOX.
In the past three months, certain tumor markers have been elevated.
As SBP highly fluctuated between 136 and 231 under treatment with (patient-carried medication) Concor (bisoprolol), Zanidip (lercanidipine) and Hyzaar (losartan + hydrochlorothiazide), please monitor this closely. The drug Atanaal (nifedipine 5mg) 1# PRNQ6H might be considered in case where the blood pressure exceeds 200mmHg.
SBP flucturated at a wide range 136~231mmHg under patient-carried antihypertensive agents Concor (bisoprolol) and Hyzaar (losartan + hydrochlorothiazide), please keep a closer eye on it.
Pre-prandial blood sugar levels were higher than 170mg/dL for 2 days; metformin 500mg BID is recommended.
[diagnosis] - 20221220 admission note
[exam findings]
[surgical operation]
[chemoimmunotherapy]
This patient has only visited our hospital in the past three months, mainly attending the hemato-oncology department, followed by the metabolism and endocrinology department. The former is for the treatment of follicular lymphoma, while the latter is for the management of type 2 diabetes mellitus.
The Uformin (metformin 500mg) 1# BID and Januvia (sitagliptin 100mg) 1# QD prescribed on 2023-05-12 by the metabolism and endocrinology department have been listed as patient-carried items in the active medication list. No medication reconciliation issues have been identified.
The last CT is dated on 2023-04-12, now in the beginning of July, a new CT scan could be considered to be arranged.
2023-01-10 lab data showed HGB 10.5g/dL, MCV 69.4fL, MCH 20.8pg, MCHC 30.0g/dL. These readings were all below their normal ranges.
Assessment based on the above lab items:
Recommendation:
[lab data]
2023-06-07 HBsAg Nonreactive
2023-06-07 HBsAg (Value) 0.28 S/CO
2023-06-07 Anti-HBc Reactive
2023-06-07 Anti-HBc-Value 7.60 S/CO
2023-06-07 Anti-HCV Nonreactive
2023-06-07 Anti-HCV Value 0.11 S/CO
2023-06-07 Anti-HBs 4.14 mIU/mL
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
According to the PharmaCloud database, this patient sporadically visits local clinics for his sleep disorder, chest pain, and acute upper respiratory infections. He has been given prescriptions with a duration of only three days, all of which are now invalid. The patient has sought medical attention multiple times due to his sleep disorder, and Eurodin (estazolam) is listed among his active medications. No reconciliation issues have been identified.
Mild hyponatremia was observed in the patient on 2023-07-05, with a serum sodium level of 131 mmol/L. The planned administration of furosemide on 2023-07-06 (concurrent with the PF regimen) may exacerbate this condition, as furosemide may cause increased sodium excretion. Please continue to monitor the patient’s sodium levels closely to determine if further intervention is needed.
[lab data]
2023-06-27 Urine-Creatinine 105.41 mg/dL
2023-06-27 U-Cr (24hr) 1633.9 mg/kg/24 hr
2023-06-27 Total Volume(24hr) 1550 mL
2023-06-27 C.C.R. 120.7 mL/min
2023-06-20 EBV DNA PCR 159 copies/mL
2023-06-14 Anti-HBc Nonreactive
2023-06-14 Anti-HBc-Value 0.06 S/CO
2023-06-14 Anti-HBs 0.40 mIU/mL
2023-06-07 RPR/VDRL Nonreactive
2023-06-07 HBsAg Nonreactive
2023-06-07 HBsAg (Value) 0.27 S/CO
2023-06-07 Anti-HCV Nonreactive
2023-06-07 Anti-HCV Value 0.11 S/CO
2023-06-07 HIV Ab-EIA Nonreactive
2023-06-07 Anti-HIV Value 0.07 S/CO
2021-08-17 RPR/VDRL Nonreactive
[exam findings] (not completed)
[consultation]
[chemotherapy]
[bedside visit: poor appetite. patient education: docetaxel, cisplatin, fluorouracil]
[lab data]
2021-11-10 ROS1 FISH NOT detected
2021-11-09 EGFR G719X not detected
2021-11-09 EGFR Exon19 del detected
2021-11-09 EGFR S768I not detected
2021-11-09 EGFR T790M not detected
2021-11-09 EGFR Exon20 ins not detected
2021-11-09 EGFR L858R not detected
2021-11-09 EGFR L861Q not detected
2021-11-08 PD-L1 (28-8) TC <1%
2021-11-03 PD-L1 (22C3) TPS<1%
2021-11-03 ALK IHC Negative
2021-10-27 Aspergillus Ag Negative
2021-10-27 Aspergillus Ag Value 0.05 Ratio
2021-10-27 Aspergillus Ag Negative
2021-10-27 Aspergillus Ag Value 0.08 Ratio
2021-10-25 Mycoplasma IgM Negative Index
2021-10-25 Mycoplasma IgM Value 0.1 Index
2021-10-22 Anti-HBs 11.64 mIU/mL
2021-10-22 HBsAg Nonreactive
2021-10-22 HBsAg (Value) 0.47 S/CO
2021-10-22 Anti-HBc Nonreactive
2021-10-22 Anti-HBc-Value 0.31 S/CO
2021-10-22 Anti-HCV Nonreactive
2021-10-22 Anti-HCV Value 0.04 S/CO
2021-10-22 HIV Ab-EIA Nonreactive
2021-10-22 Anti-HIV Value 0.06 S/CO
[exam findings] (not completed)
[MedRec]
[treatment]
2021-11-25 ~ undergoing - Tagrisso (osimertinib 80mg) 1# QD
2021-11-11 ~ 2021-11-24 - Iressa (gefitinib 250mg) 1# QD
I visited the patient around 11:10 on 2023-07-05 with the osimertinib medication pamphlet. The patient was lying in bed and his son was on a bench against the wall.
I explained to the patient and his son that he has been using osimertinib for a relatively long period of time and based on the pamphlet, I described the potential side effects to watch for during the use of this drug. The patient’s son said that the main issue was digestive tract symptoms, but other than that, everything else felt fine, and the tumor has been controlled for a good period of time, they are still satisfied with the efficacy. I left the contact information for the hospital’s pharmacy counseling window, so the patient and his family can call when needed.
[exam findings]
[MedRec]
[consultation]
As per the PharmaCloud database, this patient frequently visits RenJi Hospital (last visit on 2023-06-19) and routinely refills his prescription at a local pharmacy. The prescription includes sennoside, ubidecarenone, bisoprolol, valsartan, pitavastatin, levothyroxine, alprazolam, carbinoxamine, and dextromethorphan.
Except for carbinoxamine (a first-generation antihistamine used to treat allergic rhinitis and vasomotor rhinitis), all other drugs are included in the active medication list. However, no current diagnosis or active medical problems relating to allergic rhinitis or vasomotor rhinitis have been identified. Thus, there is no evidence of discrepancies in medication reconciliation.
[present illness] - 2023-03-20 admission note
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
2023-08-31 - FOLFOX
2023-08-04 - FOLFOX
2023-07-20 - FOLFOX
2023-06-29 - FOLFOX
2023-06-07 - FOLFOX
2023-05-15 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 760mg NS 250mL 2hr + fluorouracil 2800mg/m2 3735mg NS 500mL 46hr (FOLFOX Q2W, Oxa and 5FU 30% off for his senior age)
2023-04-24 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 770mg NS 250mL 2hr + fluorouracil 2800mg/m2 3800mg NS 500mL 46hr (FOLFOX Q2W, Oxa and 5FU 30% off for his senior age)
2023-03-24 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 775mg NS 250mL 2hr + fluorouracil 2800mg/m2 3800mg NS 500mL 46hr (FOLFOX Q2W, Oxa and 5FU 30% off for his senior age)
[note]
Refillable prescriptions for patients with chronic illnesses - ref: https://www.nhi.gov.tw/Glossary/Glossary.aspx?page=6
Our neurologist prescribed Saline (nicametate) on 2023-07-05, our endocrinologist prescribed Eltroxin (levothyroxine), and our urologist prescribed Betmiga (mirabegron), Eurodin (estazolam), Harnalidge (tamsulosin), Minirin (desmopressin), Norvasc (amlodipine), and Uretropic (furosemide) on 2023-07-08. These drugs are included in the list of active medications and reconciliation issues found.
[exam findings]
{metastatic breast cancer}
[exam findings]
[counsultation]
[immunochemotherapy]
[underdose] (not posted)
Enhertu 5.4mg/kg
[reconciliation]
[patient education]
[exam findings]
[chemotherapy]
2023-06-27 G-CSF (filgrastim 150ug) SC ST 2023-06-21 Granocyte (lenograstim 250ug) SC QD 3D
The pathology results from the breast biopsy performed on 2023-03-10 confirmed that the patient has triple-negative breast cancer (TNBC) with HER2-low characteristic (ER negative, PR negative, and Her2/neu score=1+).
Following this diagnosis, the patient underwent four cycles of liposomal doxorubicin with cyclophosphamide (AC) on 2023-03-21, 2023-04-12, 2023-05-03, and 2023-05-31. Docetaxel was then administered on 2023-06-21.
Leukopenia episodes were observed on the 20th day after the 3rd AC administration and the 6th day after the 1st docetaxel administration, with WBC levels marked with an asterisk (*) representing WBC < 2K/uL and double asterisks (**) representing WBC < 1K/uL.
To manage the episodes of leukopenia, filgrastim 150ug was given on 2023-06-27 and lenograstim 250ug was given consecutively for 3 days starting from 2023-06-21. Following these interventions, the patient’s WBC level has begun to show signs of improvement. Regular monitoring is essential to ensure this upward trend continues and to ensure the patient’s safety during further chemotherapy treatments.
The NHI in Taiwan approves the use of G-CSF for patients with non-hematologic malignancies who have a WBC count of less than 1000/uL or an ANC of less than 500/uL after chemotherapy. As the patient meets these criteria, the use of G-CSF is covered by NHI.
The patient received G-CSF with the chemotherapy regimen on 2023-06-21. For primary and secondary prophylaxis, G-CSF administration should typically begin 24 to 72 hours after completion of chemotherapy.
If the current chemotherapy regimen becomes less effective, Enhertu (fam-trastuzumab deruxtecan-nxki) may be used. This medicine is indicated for adult patients with unresectable or metastatic HER2 low (IHC 1+ or IHC 2+/ISH-) breast cancer who have received prior chemotherapy in the metastatic setting or who have experienced disease recurrence within six months of completing adjuvant chemotherapy. However, Enhertu is currently not covered by NHI in Taiwan.
[exam findings]
[consultation]
[immunochemotherapy]
Regimen Reference Order - BRST - DCH — ref: https://www.cancercare.mb.ca/export/sites/default/For-Health-Professionals/.galleries/files/treatment-guidelines-rro-files/regimen-reference-orders/breast/BRST-DCH.pdf — Updated: June 14, 2023
The patient received two cycles of the DCH regimen on 2023-06-06 and 2023-06-27. However, lab data shows that there was already a noticeable decrease in HGB levels before the initiation of the regimen, with the lowest record on 2023-05-22 at 5.6g/dL. Subsequently, multiple blood transfusions were conducted on 2023-05-22, 2023-06-05, and 2023-06-27.
Trastuzumab has been associated with a low occurrence of anemia, affecting approximately 4% of patients, with less than 1% experiencing a severe (grade 3) form, according to UpToDate. However, both docetaxel and carboplatin, which are part of the patient’s treatment regimen, are known to significantly increase the risk of anemia. Docetaxel can cause anemia in 65% to 97% of patients, with 8% to 9% experiencing severe anemia (grades 3/4). Carboplatin can cause anemia in a wide range of 21% to 90% of patients. Therefore, these drugs could be contributing to the patient’s current anemia.
MCV is at the lower end of the normal limit, and both MCH and MCHC are below the lower limit of normal, suggesting possible iron deficiency. This is further supported by the ferritin level measured on 2023-05-24, which was significantly below the lower limit of normal. It may be necessary to further investigate and address this possible iron deficiency.
[exam findings]
[consultation]
[chemotherapy]
[exam findings]
[immunochemotherapy]
The patient’s medical history, as recorded in the HIS5 database, shows previous episodes of leukopenia and thrombocytopenia in 2018-01. No chemotherapy was administered at that time.
More recently, in mid to late May 2023, the patient was diagnosed with SCC of the left tongue margin. The patient then received TPF chemotherapy on 2023-06-09 and a combination of TPF and cetuximab on 2023-06-19. Leukopenia, defined here as a WBC count of less than 3K/uL, was observed on 2023-06-16. To treat this, 3 doses of Granocyte (lenograstim 250ug) were administered on 2023-06-16, 2023-06-17, and 2023-06-21.
Given that the WBC count prior to the 2nd dose of TPF was higher than that prior to the 1st dose, and given that G-CSF was administered 2023-06-21 morning, the likelihood of severe leukopenia following the 2nd round of chemotherapy is expected to be reduced. However, the patient’s blood counts should continue to be monitored closely.
[reconciliation]
{esophageal SCC moderately differentiated T3N2M1 with lung mets}
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
The patient has been prescribed Bafen (baclofen 5mg) 1# PRNQ12H for hiccups. Metoclopramide is also included in the active medication list. Both baclofen and metoclopramide are regarded as first-line therapy for hiccups. However, it’s advisable to note that there have been numerous cases reported in the literature indicating neurotoxicity due to oral baclofen accumulation in adult patients with varying levels of renal impairment. Additionally, abrupt discontinuation of oral baclofen has been linked to altered mental status. While the current dosage seems unlikely to cause these adverse reactions, it’s worth mentioning as a precaution.
[lab data]
2023-06-16 Anti-HBc Reactive
2023-06-16 Anti-HBc-Value 8.30 S/CO
2023-06-16 Anti-HBs 0.91 mIU/mL
2023-06-16 Anti-HCV Nonreactive
2023-06-16 Anti-HCV Value 0.10 S/CO
2023-06-16 HBsAg Nonreactive
2023-06-16 HBsAg (Value) 0.27 S/CO
2021-06-10 HBsAg (NM) Negative
2021-06-10 HBsAg Value (NM) 0.359
2021-06-10 Anti-HCV (NM) Negative
2021-06-10 Anti-HCV Value (NM) 0.00292
[exam findings]
[MedRec]
[surgical operation]
There’s no available data from PharmaCloud, possibly due to the patient not providing consent for access.
Based on the records from our hospital, the patient has visited the departments of Colorectal Surgery, General and Digestive Surgery, and Hematology-Oncology in the past three months. No prescriptions were issued by the first two departments, hence, no medication reconciliation issues were found.
Several data points have indicated that the patient’s fasting plasma glucose levels are exceeding 200mg/dL, even while being under medication with Januvia (sitagliptin 100mg) 0.5# BID and Uformin (metformin 500mg) 1# BID. There are no HbA1c readings available in the HIS5 data. It is recommended to obtain an HbA1c reading to get an understanding of the average blood glucose levels over the past two to three months.
Additionally, the patient has also been prescribed Zulitor (pitavastatin 4mg) 0.5# QD, an HMG-CoA reductase inhibitor used to lower lipid levels and reduce the risk of cardiovascular disease. However, there are no diagnoses, medical problems, or lab data related to dyslipidemia. The status of the patient’s dyslipidemia might need to be checked and clarified.
In continuation of the previous pharmacist note.
[lab data]
2023-06-19 JAK2 single site mutation Undetectable
2023-06-14 HBsAg (NM) Negative
2023-06-14 HBsAg Value (NM) 0.392
2023-06-14 Anti-HCV (NM) Negative
2023-06-14 Anti-HCV Value (NM) 0.047
2023-06-14 Anti-HBc (NM) Positive
2023-06-14 Anti-HBc Value (NM) 0.009
2023-06-14 Anti-HBs (NM) Negative
2023-06-14 Anti-HBs value (NM) 4.930 mIU/mL
2023-03-13 CK 14 U/L
2023-03-03 Zinc,Zn 648 ug/L
2023-02-16 ANA Homogeneous 1:1280; Speckled 1:1280
2023-02-15 Anti-ds DNA Antibody 5.6 IU/ml
2023-02-15 Anti-ENA(Jo-1) EliA U/ml
2023-02-15 Anti Jo-1 antibody 0.3 EliA U/ml
2023-02-15 Anti-ENA (Scl-70) EliA U/ml
2023-02-15 Anti-ENA Scl-70 Ab 2.0 EliA U/ml
2023-02-14 ESR 31 mm/hr
2023-02-09 CK 10 U/L
2021-05-15 ESR 45 mm/hr
2021-03-17 LA1 52.8 sec
2021-03-17 LA2 38.0 sec
2021-03-17 LA1/LA2 ratio 1.1
2021-03-13 ESR 33 mm/hr
2020-07-04 Ferritin 101.9 ng/mL
2020-05-20 ESR 44 mm/hr
2020-05-14 Aspergillus Ag Negative
2020-05-14 Aspergillus Ag Value 0.13 Ratio
2020-05-06 LA1 51.4 sec
2020-05-06 LA2 39.4 sec
2020-05-06 LA1/LA2 ratio 1.1
2020-05-05 Anti-beta2-glycoprotein-I Ab 3.5 U/mL
2020-05-05 Anti-cardiolipin-IgM 3.0 MPL U/mL
2020-05-05 Anti-cardiolipin IgG GPL-U/mL
2020-05-05 Anti-Cardiolopin 8.0 GPL-U/mL
2020-05-05 Anti-ENA Sm 7.0 EliA U/ml
2020-05-05 Anti-ENA RNP 2.4 EliA U/ml
2020-05-05 Anti-ds DNA Antibody 14 IU/ml
2020-05-05 C4 30.4 mg/dL
2020-05-05 C3 102.8 mg/dL
2020-04-20 Aspergillus Ag Positive
2020-04-20 Aspergillus Ag Value 0.5 Ratio
2020-04-20 Anti-ENA SS-A (Ro) >2400 EliA U/ml
2020-04-20 Anti-ENA SS-B (La) >3200 EliA U/ml
2020-04-20 ANA Homogeneous ; 1:1280
2020-04-17 Cryptococcus Ag Negative
2020-04-17 Antibody Identification Anti-M
2020-04-15 Anti-ENA Sm 7.5 EliA U/ml
2020-04-15 Anti-ENA RNP 2.4 EliA U/ml
2020-04-15 Anti-ds DNA Antibody 14 IU/ml
[exam findings]
[MedRec]
Based on the PharmaCloud database, our hospital is the sole medical provider for the patient in the past 3 months. No issues related to medication reconciliation have been identified.
Cyclophosphamide is a potential therapeutic option for severe, refractory cases of dermatomyositis/polymyositis, and it is often administered as an adjunctive treatment. The recommended oral dose typically ranges from 1.5 to 2 mg/kg/day (ref: UpToDate). As of 2023-06-18, the patient’s body weight is 53.3kg, and the current prescription of cyclophosphamide at 50mg QD is below the suggested dosage range. Please continue to monitor the treatment’s effectiveness and consider whether a dose adjustment might be required.
[MedRec]
[chemotherapy]
[exam findings]
[consultation] (not completed)
[immunochemotherapy] (not completed with small molecular targeted therapeutics)
This year, there have only been 2 episodes of leukopenia with a WBC count less than 3K/uL, occurring on 2023-01-14 and 2023-04-06. The injectable Cyramza (ramucirumab) has been used since 2022-03-22. Oral TKI treatment was divided at 2023-03-15: before this date, the patient was taking Giotrif (afatinib), and after this date, the patient was taking Tagrisso (osimertinib). The relationship between the usage of these drugs and the WBC level is shown in the table below, with asterisks indicating the dates when the WBC count was less than 3K/uL.
The administration time of ramucirumab does not appear to directly correlate with the episodes of leukopenia. However, all three drugs mentioned above have been reported to be associated with leukopenia. For ramucirumab, neutropenia has been reported in 5% to 24% of patients, with grade >=3: 8%. Afatinib has been associated with lymphocytopenia in 38% of patients, with grades 3/4: 9%, and decreased white blood cell count in 12% of patients, with grades 3/4: 1%. Osimertinib has been reported to cause leukopenia in 54% of patients, neutropenia in 26% to 41% of patients, with grades 3/4: <= 3%. (ref: UpToDate)
In conclusion, it is difficult to determine whether leukopenia is caused by a specific drug or a combined effect of all drugs.
As per the reimbursement guidelines of Taiwan’s NHI, the administration of G-CSF is approved for patients with non-hematological malignancies who demonstrate a WBC count of less than 1000/uL or an ANC of less than 500/uL following chemotherapy. In this particular patient’s case, the specific criteria are not fulfilled, which means that the use of G-CSF is not covered by the NHI, if G-CSF is desirable.
[diagnosis]
[past history]
[allergy]
[family history]
[exam findings] (not completed)
[MedRec]
[surgical operation]
[chemotherapy]
[optional addition of antiemetics]
Upon reviewing the PharmaCloud database, no issues with medication reconciliation were found.
According to the records from the neurosurgery OPD, this patient has a long history of alcohol use. The patient also has a history of epilepsy, which is currently managed with Depakine (valproate). This medication is not typically recommended for use in patients with hepatic disease because its clearance is reduced in liver impairment. Therefore, it might be prudent to order comprehensive LFTs for further assessment.
[past history] - 2023-03-23 admission note
[allergy]
[family history]
[exam findings]
[MedRec]
[MultiTeam]
[surgical operation]
[chemoimmunotherapy]
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
Neoadjuvant Chemotherapy regimen in In-hospital “Prescription Collection of Chemotherapy for Head and Neck Cancer” protocol (dated 2022-02-11).
Docetaxel, cisplatin and fluorouracil induction chemotherapy followed by chemoradiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX324) 2023-04-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F65438&topicKey=ONC%2F85694
Cycle length: Every 21 days for three cycles.
Regimen
Docetaxel, cisplatin, and fluorouracil induction chemotherapy followed by radiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX323) 2023-04-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F72461&topicKey=ONC%2F85694
Cycle length: Every 21 days for four cycles.
Regimen
According to the PharmaCloud database, all of this patient’s prescribed medications for the past 3 months have been provided exclusively by our hospital. There are no identified medication reconciliation issues.
The leukocytosis seems to be improving as the patient’s WBC count is nearing ULN. The medications recently used, which include esomeprazole, entecavir, and megestrol, have been reviewed, but none of them are known to significantly affect the WBC count. At the moment, there don’t seem to be any medication-related problems associated with this issue.
Hypomagnesemia has been noted. This might be due to the use of the TPF regimen, which contains cisplatin, and/or the PPI, esomeprazole. During the regimen administration and hospital stay, the patient receives magnesium supplements. Given that hypomagnesemia has been persistent for several months, it may be beneficial to consider magnesium supplementation upon discharge.
[lab data]
[exam findings]
2023-06-08 MRI - L-spine
2023-05-20 MRI - brain
2023-05-19 CXR
2023-05-19 ECG
2023-04-24 Patho - colon biopsy
2023-04-21 Patho - soft tissue nontumor/mass/lipoma/debridement (Y2)
2023-04-21 CT - abdomen
2023-04-21 Bone densitometry - spine + hip
2023-04-17 CT - chest
2023-03-14 Whole body PET scan
2023-02-08 Tc-99m MDP
2023-01-17 MRI - upper abdomen
2023-01-07 CT - chest
2022-11-09, -09-07 CXR
2022-07-08 CT - chest
2022-05-18 Pure Tone Audiometry, PTA
2022-05-11 Pure Tone Audiometry, PTA
2022-04-27, 2022-04-20 CXR
2022-03-28, 2021-12-22 Tc-99m MDP whole body bone scan
2021-12-20 KUB
2021-12-09 CT - lung/mediastinum/pleura
2021-10-25 Patho - soft tissue biopsy, simple excision, non lipoma
2021-10-21 CT - whhole abdomen, pelvis
2021-09-08 CT - lung/mediastinum/pleura
2021-09-08 CT - liver, spleen, biliary duct, pancreas
2021-07-16 Patho - liver biopsy
2021-07-07 Tc-99m MDP whole body bone scan
2020-12-17 ROS1 FISH not detected
2020-12-11 EGFR, ALK IHC, PD-L1(22C3) S2020-18026 (bronchus biopsy)
2020-11-25 Patho - bronchus biopsy
2020-11-13 CT - lung/mediastinum/pleura
2020-08-12 CT - lung/mediastinum/pleura
2020-06-30 Patho - Ureter resection
2020-06-29 Patho
2020-06-13 CT - whole abdomen, pelvis
2020-03-30 CT - lung/mediastinum/pleura
2019-12-30 CT - lung/pleura
2019-09-18 CT - lung/pleura
2019-06-12 CT - lung/pleura
2019-04-11 MRI - L-spine
2019-03-15 MRI - brain
2019-03-14 Surgical pathology Level IV
2019-03-12 CT - lung/pleura
2019-03-02 CT - brain
2018-06-06 Surgical pathology Level IV
2018-05-31 Low-dose CT - lung cancer screening
[MedRec] (not completed)
[consultation]
[surgical operation]
[chemotherapy]
NCCN Non-Small Cell Lung Cancer Evidence Block 20220316 p89 — targeted therapy or immunotherapy for advanced or metastatic NSCLC
-EGFR S768I, L861Q, and/or G719X - First-line therapy -Afatinib -Erlotinib -Dacomitinib -Gefitinib -Osimertinib - Subsequent therapy -Osimertinib9
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
t:5, Lt:4+ , Lower limbs->
Rt:5, Lt:4[chemotherapy]
[exam findings]
[surgical operation]
[immunochemotherapy]
2023-06-12 - trastuzumab 600mg SC 5min (Herceptin)
2023-05-17 - cyclophosphamide 300mg/m2 457mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 53mg D5W 250mL 2hr (AC(lipo) Endoxan 50%)
betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL2023-04-25 - cyclophosphamide 600mg/m2 970mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 57mg D5W 250mL 2hr (AC(lipo))
2023-03-28 - cyclophosphamide 600mg/m2 996mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr (AC(lipo))
2023-02-13 - cyclophosphamide 600mg/m2 992mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr (AC(lipo))
betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg POOn 2023-01-02, breast mastectomy with regional lymph node pathology revealed the disease to be pT1cN1a; if cM0, stage IIA. Adjuvant chemotherapy with trastuzumab is indicated for this disease.
The dose-dense AC regimen (cyclophosphamide 600mg/m2, original doxorubicin 60mg/m2 replaced by liposomal doxorubicin 35mg/m2) was administered on 2023-02-13, 2023-03-28, 2023-04-25, 2023-05-17, with cyclophosphamide at 50% of the planned dose on the last administration.
The timeline of the patient’s WBC level is organized in the following table, with asterisks indicating instances where the WBC count was less than 2K/uL. The lowest WBC values occurred 2 to 4 weeks after administration of the adjusted AC regimen, suggesting a prolonged nadir or slow recovery of the white blood cells given the dosage and frequency at that time, even G-CSF was administered.
According to Taiwan’s NHI reimbursement rules, the use of G-CSF is permitted for patients with non-hematological malignancies who have a WBC count of less than 1000/uL or an ANC of less than 500/uL post-chemotherapy. In this patient’s case, the criteria are not met, so G-CSF is not covered by the NHI.
Granocyte (lenograstim) was administered concurrently with the adjusted AC regimen on 2023-03-28, 2023-04-25, and 2023-05-17. It’s recommended for primary and secondary prophylaxis that G-CSF administration typically starts 24 to 72 hours after the end of chemotherapy treatment (https://www.uptodate.com/contents/use-of-granulocyte-colony-stimulating-factors-in-adult-patients-with-chemotherapy-induced-neutropenia-and-conditions-other-than-acute-leukemia-myelodysplastic-syndrome-and-hematopoietic-cell-transplantation). ref(1): Delayed Granulocyte Colony-Stimulating Factor (G-CSF) Administration after Chemotherapy Reduces Total G-CSF Doses without Affecting Neutrophil Recovery in a Randomized Clinical Study in Children with Solid Tumors. Pediatr Hematol Oncol. 2020;37(8):665-675. ref(2): Efficacy of delayed administration of post-chemotherapy granulocyte colony-stimulating factor: evidence from murine studies of bone marrow cell kinetics. Exp Hematol. 2008;36(1):9-16.
[diagnosis]
[exam findings]
[radiotherapy]
[chemotherapy]
2023-07-03 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX Q2W)
2023-06-13
2023-05-23
2023-04-28
2023-04-06
2023-03-24
2023-03-14
2023-03-23
2023-02-06 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX Q2W)
2023-01-13 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX Q2W)
The medications Janumet (sitagliptin, metformin), Kentamin (B1, B6, B12), Diovan (valsartan), and Livalo (pitavastatin) were prescribed at Tri-Service General Hospital on 2023-06-10 and recently refilled on 2023-06-30. However, none of these drugs are currently included in the active medication list. Please verify whether these medications are still required for the patient’s current condition.
[lab data]
2023-05-10 Blood gas (Vein) 2023-05-10 PH 7.499
2023-05-10 PCO2 39.6 mmHg
2023-05-10 PO2 82.5 mmHg
2023-05-10 HCO3 30.1 mmol/L
2023-05-10 ctCO2 31.3 mmol/L
2023-05-10 Base Excess 7.1 mmol/L
2023-05-10 BEecf 6.9 mmol/L
2023-05-10 SBC 29.7 mmol/L
2023-05-10 O2 Saturation 97.2 ％
2023-05-10 Blood Osmolality 291 mOsm/Kg
2023-05-08 Blood gas (Vein) 2023-05-08 PH 7.488
2023-05-08 PCO2 47.6 mmHg
2023-05-08 PO2 47.9 mmHg
2023-05-08 HCO3 35.3 mmol/L
2023-05-08 ctCO2 36.7 mmol/L
2023-05-08 Base Excess 10.6 mmol/L
2023-05-08 BEecf 11.9 mmol/L
2023-05-08 SBC 33.0 mmol/L
2023-05-08 O2 Saturation 87.9 ％
2023-05-08 Free Light Chain κ/λ (blood) ratio 2023-05-08 FKLC 8.6
mg/L
2023-05-08 FLLC 10900.0 mg/L
2023-05-08 FK/FL ratio <0.01 ratio
2023-05-02 Protein EP 2023-05-02 Protein, total 6.1 g/dL
2023-05-02 Albumin 59.6 %
2023-05-02 Alpha-1 3.2 %
2023-05-02 Alpha-2 16.6 %
2023-05-02 Beta 11.1 %
2023-05-02 Gamma 9.5 %
2023-05-02 M-peak Negative
2023-05-02 A/G Ratio 1.50
2023-04-29 B2-Microglobulin 13021 ng/mL
2023-04-28 IgG (blood) 687 mg/dL
2023-04-27 Ca (Calcium) 2.89 mmol/L
2023-04-27 LDH 706 U/L
2023-03-17 CD45+Total leukocyte 149733 /uL
2023-03-17 %CD34+ 0.56 %
2023-03-17 CD34+ Count 846 /uL
2023-03-17 HPC Ratio 0.15 %
2023-03-17 HPC# 0.029 10^3/ul
2023-03-16 CD45+Total leukocyte 127292 /uL
2023-03-16 %CD34+ 0.67 %
2023-03-16 CD34+ Count 848 /uL
2023-03-16 HPC Ratio 0.25 %
2023-03-16 HPC# 0.036 10^3/ul
2023-03-15 CD45+Total leukocyte 117620 /uL
2023-03-15 %CD34+ 0.78 %
2023-03-15 CD34+ Count 915 /uL
2023-03-15 HPC Ratio 0.47 %
2023-03-15 HPC# 0.038 10^3/ul
2023-03-15 Ca (Calcium) 2.21 mmol/L
2023-03-15 Alkaline phosphatase 74 U/L
2023-03-15 LDH 235 U/L
2023-03-10 Ca (Calcium) 2.18 mmol/L
2023-03-10 Alkaline phosphatase 69 U/L
2023-03-10 LDH 183 U/L
2023-03-05 Alkaline phosphatase 74 U/L
2023-03-05 LDH 197 U/L
2023-03-05 Total protein 6.3 g/dL
2023-03-05 PT 10.4 sec
2023-03-05 INR 1.01
2023-03-05 APTT 26.7 sec
2023-02-20 Free Light Chain κ/λ (blood) ratio
2023-02-20 FKLC 13.3 mg/L
2023-02-20 FLLC 101 mg/L
2023-02-20 FK/FL ratio 0.13 ratio
2023-02-17 Protein EP 2023-02-17 Protein, total 5.4 g/dL
2023-02-17 Albumin 58.3 %
2023-02-17 Alpha-1 3.1 %
2023-02-17 Alpha-2 11.8 %
2023-02-17 Beta 13.1 %
2023-02-17 Gamma 13.7 %
2023-02-17 M-peak Negative
2023-02-17 A/G Ratio 1.40
2023-02-16 B2-Microglobulin 2245 ng/mL
2023-02-15 IgG (blood) 588 mg/dL
2023-02-15 HBsAg Nonreactive
2023-02-15 HBsAg (Value) 0.29 S/CO
2023-02-15 Anti-HBc Nonreactive
2023-02-15 Anti-HBc-Value 0.09 S/CO
2023-02-15 Anti-HCV Nonreactive
2023-02-15 Anti-HCV Value 0.06 S/CO
2023-02-15 Total protein 5.7 g/dL
2023-02-15 Ca (Calcium) 2.22 mmol/L
2023-02-15 LDH 206 U/L
[exam findings]
[consultation]
[MedRec]
[chemotherapy]
Bortezomib (Velcade), lenalidomide (Revlimid), and “low dose” dexamethasone (VRd) for multiple myeloma 2023-05-10 https://www.uptodate.com/contents/image?imageKey=ONC%2F91054&topicKey=HEME%2F6647
Cycle length: 21 days.
Regimen
Pretreatment considerations:
Monitoring parameters:
Suggested dose modifications for toxicity:
DVd (Daratumumab + Velcade (bortezomib) + dexamethasone) is a Chemotherapy Regimen for Multiple Myeloma (MM) 2023-05-10 https://www.chemoexperts.com/dvd-daratumumab-velcade-bortezomib-dexamethasone.html
NHS - Chemotherapy Protocol - Myeloma - DVd (Weekly) Bortezomib-Daratumumab-Dexamethasone (cycles 1 to 8) https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Myeloma/DVd-Weekly-Daratumumab-Bortezomib-Dexamethasone-Cycles-1-to-8.pdf
The DVd regimen (Daratumumab + Velcade (bortezomib) + dexamethasone) was initiated on 2023-05-12. Pancytopenia was observed, but it’s important to note that bicytopenia (anemia and thrombocytopenia) was already present even before the regimen started. Furthermore, the fluctuations in HGB and PLT levels are smaller than those in the WBC count. This can be attributed to the fact that the patient has received multiple blood transfusions at our hospital (on 2023-03-16, 2023-04-28, 2023-05-09, 2023-05-15, 2023-05-19, 2023-05-26, 2023-05-31, 2023-06-08, 2023-06-13), which have helped replenish red blood cells and platelets.
2023-06-13 PLT 45 x10^3/uL
2023-06-11 PLT 10 x10^3/uL
2023-06-08 PLT 51 x10^3/uL
2023-06-05 PLT 24 x10^3/uL
2023-06-02 PLT 34 x10^3/uL
2023-05-31 PLT 14 x10^3/uL
2023-05-29 PLT 54 x10^3/uL
2023-05-28 PLT 89 x10^3/uL
2023-05-26 PLT 8 x10^3/uL
2023-05-24 PLT 33 x10^3/uL
2023-05-23 PLT 57 x10^3/uL
2023-05-22 PLT 19 x10^3/uL
2023-05-19 PLT 78 x10^3/uL
2023-05-17 PLT 25 x10^3/uL
2023-05-15 PLT 58 x10^3/uL
2023-05-12 PLT 15 x10^3/uL
2023-05-10 PLT 49 x10^3/uL
2023-05-08 PLT 23 x10^3/uL
2023-06-13 HGB 7.7 g/dL
2023-06-11 HGB 7.5 g/dL
2023-06-08 HGB 6.7 g/dL
2023-06-05 HGB 7.4 g/dL
2023-06-02 HGB 8.7 g/dL
2023-05-31 HGB 7.5 g/dL
2023-05-29 HGB 8.5 g/dL
2023-05-28 HGB 8.1 g/dL
2023-05-26 HGB 8.9 g/dL
2023-05-24 HGB 9.4 g/dL
2023-05-23 HGB 8.5 g/dL
2023-05-22 HGB 7.6 g/dL
2023-05-19 HGB 8.4 g/dL
2023-05-17 HGB 9.0 g/dL
2023-05-15 HGB 6.8 g/dL
2023-05-12 HGB 8.8 g/dL
2023-05-10 HGB 8.2 g/dL
2023-05-08 HGB 8.0 g/dL
Since the VRd (bortezomib, lenalidomide, dexamethasone) regimen has already been utilized from 2022-08-17 to 2022-12-29, and the DVd regimen is preferred in patients who are refractory to full doses of lenalidomide or a lenalidomide-containing triplet, the choice of DVd regimen is reasonable in this case. The major toxicities of the DVd regimen include peripheral neuropathy, transient cytopenias, acute or delayed hypersensitivity reaction, fatigue, and nausea. At present, the WBC count has exceeded the upper limit of normal, reversing the previous leukopenia and presenting as a problem of leukocytosis.
[DVd regimen renal dosing checked]
The recent lab data indicates that the patient’s renal function has stopped deteriorating and shows signs of slight recovery.
For patients with CrCl between 15 to 89 mL/minute, there are no dosage adjustments provided in the daratumumab manufacturer’s labeling. Studies show that this range of renal function does not significantly affect the pharmacokinetics of daratumumab. Additionally, no dosage adjustment is necessary for bortezomib in patients with renal insufficiency. For the current treatment regimen of multiple myeloma, there is no need for dosage adjustment.
[tube feeding]
[diagnosis] - 2023-04-01 admission note
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
Xgeva (denosumab 120mg) CXGEV01
[exam findings]
The two medications, Plaquenil (hydroxychloroquine) and dipyridamole, which were prescribed by our Rheumatology and Immunology OPD on 2023-05-15, are correctly listed on the active medication list. No issues with medication reconciliation were identified.
Given that hematemesis was just added to the patient’s medical problem list on 2023-06-08, the inclusion of tranexamic acid could be beneficial in reducing gastrointestinal bleeding.
[IVIG usage]
According to UpToDate, immune globulin can be used for acute disseminated encephalomyelitis, IV: 400 mg/kg once daily for 5 days.
Based on the patient’s body weight of 80kg and Privigen at 5gm per vial, a dosage schedule of 7-7-6-6-6 vials over 5 days appears to fulfill the recommended dosage.
While the package insert doesn’t specify a need for dilution, if dilution is preferred, D5W can be used as the solvent.
Infusions should ideally begin at a rate of 0.5 to 1 mL/kg/hour for the first 15 to 30 minutes. If no adverse reactions occur, the rate can be incrementally increased every 15 to 30 minutes to a maximum of 3 to 6 mL/kg/hour. This information is referenced from https://www.ncbi.nlm.nih.gov/books/NBK554446/. An alternative infusion rate reference can be found at https://www.gov.nl.ca/hcs/files/bloodservices-resources-pdf-adult-invig-inf-table.pdf.
[diagnosis] - 2023-03-27 admission note
[past history]
[allergy]
[family history]
[lab data]
[exam findings]
[consultation]
[radiotherapy]
[chemoimmunotherapy]
[tube feeding]
According to the package insert of Valcyte (valganciclovir), once ingested, it rapidly converts to ganciclovir, which has been shown in animal studies to be mutagenic, teratogenic, and carcinogenic. This morning I called the drug supplier (YuLi Co., Ltd.), who advised against direct contact with the drug substance on the mucous membranes to avoid exposure, so they don’t recommend crushing or splitting the pill by hand. However, they suggested that the pill could be broken into smaller pieces without the operator’s hands directly touching it, dissolved in an appropriate amount of drinking water, and then administered with food via tube feeding.
Lab data from early Feb 2023 showed a short trough. However, recent results indicate that the SCC antigen has doubled compared to late Dec 2022.
The patient is currently being treated with Valcyte (valganciclovir), Morcasin (sulfamethoxazole/trimethoprim), and Mycostatin (nystatin) for suspected respiratory infections.
During this hospital stay, no issues with medication reconciliation were identified, and the drugs recently prescribed and listed in the NHI PharmaCloud System were properly prescribed as self-carried items to address the patient’s underlying conditions.
There is no specific pharmacist shift handover to follow in this patient.
[Zavicefta 2g/0.5g powder for concentrate for solution for infusion - Usage and Precautions ] for the patient’s primary nurse
[exam findings]
[consultation]
{gastric cancer with peritoneal seeding, pT4aN2M1, stage IV, (poorly cohesive carcinoma, signet-ring cell type) s/p total gastrectomy with D2 LN dissection & CCRT}
[compatibility]
There is no compatibility information available in Micromedex for concurrent administration of Nako No.5 and Oliclinomel N4-550E.
Nako No.5 injection contains: - sodium chloride - sodium acetate anhydrous - potassium acetate - magnesium chloride 6H2O - potassium phosphate monobasic - dextrose monohydrate
Oliclinomel N4-550E Emulsion for Infusion contains: - sodium acetate 3H2O - sodium glycerophosphate 5H20 - potassium chloride - magnesium chloride 6H2O - glucose monohydrate - calcium chloride 2H2O
The electrolyte components in both Nako No.5 and Oliclinomel N4-550E share a high degree of similarity, which suggests that they are unlikely to be incompatible when administered concurrently through a Y-line immediately prior to administration.
{SCC of esophagus, lower third, with mediastinal & SCF LAPs and multiple brain metastases, stage IV}
[diagnosis] - 20230110 admisstion note
[past history]
[family history]
[exam findings]
Port-A catheter inserted into SVC via left subclavian vein.
approriately positioned endotracheal tube in place
s/p VATS esophagectomy and gastric tube reconstruction with gastric tube inserted
Right internal jugular central venous catheter with tip in the SVC
s/p right chest tube in place, its tip directed superomedially, projecting over Rt upper hemithorax
s/p left chest tube in place, its tip directed superomedially, projecting over 6th rib
extensive increased opacity over Rt lung field
Lung volume reduction and increased opacity over RLL
Subcutaneous emphysema in the right neck and chest wall
2022-07-15 Patho - esophagus subtotal/total resection
2022-07-01 Pulmonary Flow Volume Loop
2022-06-27 CXR
2022-06-01 Patho - bronchus biopsy
2022-05-19 CT - chest
2022-03-10 Patho - esophageal biopsy
2022-03-01 Esophagography
2022-01-17 MRI - brain
2022-01-14 CT - lung/mediastinum/pleura
2021-10-11 CT - lung/mediastinum/pleura
2021-10-08 CT - brain
2021-04-28 Whole body PET scan
2021-04-28 CT - lung/mediastinum/pleura
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2 + NS 250mL D2
2022-12-21 - nivolumab 3mg/kg 200mg 30min D1 + oxaliplatin 85mg/m2 145mg 2hr D2 + leucovorin 400mg/m2 700mg 2hr D2 + fluorouracil 2800mg/m2 4800mg 44hr D2 (Opdivo/FOLFOX6 Q2W)
2022-12-01 - nivolumab 3mg/kg 180mg 30min D1 + oxaliplatin 85mg/m2 148mg 2hr D2 + leucovorin 400mg/m2 680mg 2hr D2 + fluorouracil 2800mg/m2 4800mg 44hr D2 (Opdivo/FOLFOX6 Q2W)
2022-04-22 - cisplatin 40mg/m2 77mg 4hr + leucovorin 400mg/m2 775mg 2hr + fluorouracil 2800mg/m2 5430mg 46hr
2022-03-29 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
2022-03-14 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
2022-02-15 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
2022-01-24 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
2022-01-11 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
2021-12-22 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
2021-12-07 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
2021-11-18 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)
2021-11-02 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)
2021-10-18 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5435mg 46hr (FOLFOX)
2021-09-29 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5435mg 46hr (FOLFOX)
2021-08-24 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)
2021-08-10 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)
2021-07-27 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)
2021-07-14 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)
[exam findings]
[MedRec]
[chemotherapy]
Nanoparticle albumin bound paclitaxel (nab-paclitaxel) 2023-05-24 https://www.uptodate.com/contents/nanoparticle-albumin-bound-paclitaxel-nabpaclitaxel-drug-information
[exam findings]
[MedRec]
[consultation]
This patient visited a local clinic on 2023-05-11 for his primary hypertension (PharmaCloud only reveals one main diagnosis, there should be also diabetes diagnosed) and be prescribed with amlodipine, losartan and glimepiride. Currently Norvasc (amlodipine), Amepiride (glimepiride) and 與 losartan 同藥理作用的 Olmetec (olmesartan) are shown in the active medication list, no reconciliation issue identified.
2023-05-19 anaerobic culture for deep neck wound/pus showed peptostreptoccus spp. 3+
[exam findings]
Laterality: right [MedRec]
[consultation]
[chemotherapy]
Based on the PharmaCloud database, this patient has only sought medical care at our hospital in the past three months. On 2023-05-27, our metabolic physician recently prescribed refillable medications including Uformin (metformin), Trajenta (linagliptin), Lipanthyl (fenofibrate), and Zulitor (pitavastatin). These drugs have been correctly integrated into the current active medication list without any issues in medication reconciliation.
[exam findings]
[surgical operation]
[chemotherapy]
2023-05-16 - paclitaxel 135mg/m2 260mg NS 300mL 3hr + carboplatin AUC 5 800mg NS 250mL 2hr + [paclitaxel 40mg/m2 77mg + cisplatin 30mg/m2 58mg + gentamicin 40mg + sodium bicarbonate 2800mg NS 800mL] IP 1hr
2023-04-23 - [Liposome doxorubicin 30mg/m2 60mg D5W 250mL 90min + carboplatin AUC 5 700mg NS 250mL] IP (HIPEC)
2023-03-28 - paclitaxel 175mg/m2 345mg NS 300mL 1hr + carboplatin AUC 5 750mg NS 250mL 2hr
2023-03-07 - paclitaxel 175mg/m2 345mg NS 300mL 1hr + carboplatin AUC 5 750mg NS 250mL 2hr
2023-02-09 - paclitaxel 175mg/m2 345mg NS 300mL 1hr + carboplatin AUC 5 750mg NS 250mL 2hr
2023-01-20 - paclitaxel 175mg/m2 360mg NS 300mL 1hr + carboplatin AUC 5 740mg NS 250mL 2hr
[exam findings]
[chemotherapy]
[note]
Systemic Therapy for Endometrial Carcinoma - Endometrial Carcinoma - NCCN Clinical Practice Guidelines in Oncology - NCCN Evidence Blocks - Version 2.2023 - April 28, 2023 - ENDO-D
Primary or Adjuvant Therapy (Stage I-IV)
Recurrent Disease
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemoimmunotherapy]
2023-05-25 - docetaxel 60mg/m2 100mg NS 250mL 1hr + leucovorin 300mg/m2 520mg NS 250mL 2hr + fluorouracil 300mg/m2 520mg NS 250mL 10min + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
2023-04-21 - docetaxel 60mg/m2 100mg NS 250mL 1hr + leucovorin 300mg/m2 520mg NS 250mL 2hr + fluorouracil 300mg/m2 520mg NS 250mL 10min + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
2023-03-09 - [oxaliplatin 300mg/m2 530mg D5W 3000mL + sodium bicarbonate 4200mg + gentamicin] IP 30min
2022-07-25 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4760mg NS 500mL 46hr
2022-07-05 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4760mg NS 500mL 46hr
2022-06-21 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4790mg NS 500mL 46hr
2022-06-08 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4770mg NS 500mL 46hr
2022-05-11 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4750mg NS 500mL 46hr
2022-04-19 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4790mg NS 500mL 46hr
2022-03-28 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr
2022-03-14 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr
2022-02-24 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr
2022-02-11 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr
2022-01-19 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr
2022-01-03 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr
[past history]
[family history]
[exam findings]
[MedRec]
[chemotherapy]
[note: R-COP, R-mini-CHOP, R-CHOP21, EPOCH-R, daEPOCH]
R-CVP 2023-05-19 https://www.cancer.gov/about-cancer/treatment/drugs/r-cvp
Initial treatment of advanced stage diffuse large B cell lymphoma 2023-05-19 https://www.uptodate.com/contents/initial-treatment-of-advanced-stage-diffuse-large-b-cell-lymphoma
R-mini-CHOP - SPECIAL SCENARIOS - Older adults
Pretreatment evaluation
R-mini-CHOP Treatment
A pre-treatment phase of a systemic steroid, with or without rituximab, may improve the patient’s performance status (PS) and facilitate treatment with R-mini-CHOP.
Frail patients who require symptom palliation but cannot tolerate R-mini-CHOP may benefit from a systemic steroid (with or without rituximab) or single chemotherapeutic agents.
Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP21) for non-Hodgkin lymphoma 2023-05-19 https://www.uptodate.com/contents/image?topicKey=HEME%2F4729&imageKey=ONC%2F63586
Cycle length: 21 days.
Regimen
Infusional etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R) for non-Hodgkin lymphoma 2023-05-19 https://www.uptodate.com/contents/image?topicKey=HEME%2F4729&imageKey=ONC%2F88411
Cycle length: 21 days.
Regimen
Chemotherapy regimens for non-Hodgkin lymphoma: Dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (daEPOCH) 2023-05-19 https://www.uptodate.com/contents/image?topicKey=ONC%2F85686&imageKey=ONC%2F105216
(not posted)
The patient’s current active medication list correctly reflects the refillable prescriptions provided by our gastroenterologist and endocrinologist. These medications include Spasmotin (hyoscyamine), Strocain (oxethazaine), Alpraline (alprazolam), MgO from the gastroenterologist, and Crestor (rosuvastatin), Galvus Met (vildagliptin, metformin), Norvasc (amlodipine), Relinide (repaglinide), Uformin (metformin), Tresiba FlexTouch (insulin degludec), and dipyridamole from the endocrinologist. As such, there are no identified medication reconciliation issues at this time.
Hyoscyamine, a tropane alkaloid and the levo-isomer of atropine, is often employed to manage acute episodes of gastric secretion, visceral spasm, hypermotility in spastic colitis, pylorospasm, and associated abdominal cramps. Additionally, it can serve as adjunctive therapy in the treatment of peptic ulcers. However, considering the patient’s constipation (in the clinical problem list), and the fact that metoclopramide is concomitantly prescribed to mitigate potential nausea and vomiting effects caused by the R-COP regimen, it might be advisable to temporarily withhold hyoscyamine during the chemoimmunotherapy sessions.
The HbA1c level, which reflects the average blood glucose level over the past two to three months, has reached a record high of 8.1%. This suggests that the patient’s current diabetes management plan may not be effectively controlling her blood sugar levels.
Despite the patient’s current use of antidiabetic agents Galvus Met (vildagliptin, metformin), Relinide (repaglinide), Uformin (metformin), and Tresiba FlexTouch (insulin degludec), recent blood glucose readings have exceeded 200mg/dL (187mg/dL at 17:03 2023-05-09, 204mg/dL 20:25 2023-05-09 and 202mg/dL at 06:13 2023-05-10). This suggests that the patient’s glycemic control is currently suboptimal. An adjustment to the patient’s insulin regimen may be needed. It is recommended that the dose of insulin degludec be increased to 7 or 8 units, with close monitoring of the patient’s blood glucose levels. This adjustment should be particularly considered during periods when the patient is receiving steroids (as part of the R-COP regimen).
Due to the patient’s senior age, R-COP was selected over R-CHOP as the regimen. The patient is currently admitted for the second cycle of this chemoimmunotherapy.
According to the available data from the past 6 months, there have been no instances of leukopenia or thrombocytopenia observed. However, there has been a slight presence of anemia during this time period, which is unlikely to be caused by the R-COP regimen since it was present even before the start of treatment.
Please ensure that the patient is adequately hydrated and monitor her BUN readings, which have been trending upward, while serum creatinine remains normal.
This patient has a history of diabetes, and despite taking Uformin (metformin 500mg) 1# BID, Galvus Met (vildagliptin 50mg + metformin 500mg) 1# BID, and Relinide (repaglinide 1mg) total 2# daily (the daily dose of metformin has already reached 2g and should not be increased further), her blood sugar levels range from 284 to 301mg/dL. R-COP chemotherapy regimen includes high doses of prednisolone, which can contribute to hyperglycemia. Similar to the management of type 2 diabetes, stepwise intensification of antihyperglycemic therapy and frequent re-evaluation should be considered in cases of steroid-induced hyperglycemia. ref: A Practical Guide for the Management of Steroid Induced Hyperglycaemia in the Hospital. J Clin Med. 2021;10(10):2154. Published 2021 May 16. doi:10.3390/jcm10102154
The addition of a rapid-acting insulin (RI) may be beneficial for controlling hyperglycemia in this patient. However, careful monitoring of blood glucose levels and titration of insulin dose are necessary to prevent hypoglycemia. It is also important to continue evaluating and adjusting the patient’s antihyperglycemic therapy as needed.
This patient is diagnosed with high grade DLBCL (2023-01-30 patho IHC (not FISH): MYC + 30-40%, BCL2 + 90%, BCL6 + 90%; triple hit)
International Prognostic Index = 3 => Risk Group: High-intermediate, 5-yr OS 43% (ref: UpToDate)
Considering the patient is elderly, R-CHOP might be an alternative to R-DA-EPOCH. It might be necessary to perform a cardiac ultrasound prior to the treatment in order to establish a baseline. A lumbar puncture may be necessary if the CNS is involved.
[drug identification]
[diagnosis] - 2022-12-15 admission note
[exam findings]
[body fluid]
[MedRec]
[consultation]
[surgical operation]
[chemoimmunotherapy]
[note]
PREVIOUSLY UNTREATED PATIENTS - Trastuzumab plus pertuzumab plus a taxane - 2022-11-24 UpToDate - https://www.uptodate.com/contents/systemic-treatment-for-her2-positive-metastatic-breast-cancer
[tube feeding]
A grinding substitution method for Tykerb (lapatinib 250mg) tab
After over 15 kg of weight loss between late August and early December in 2022, the patient’s weight has remained at approximately 41kg for one month, with no further noticeable decline in her weight.
The elevated D-dimer readings are getting closer to the normal limits in a gradual manner. Given that the half-life of the D-dimer is only 15.8 (13.1 - 23.1) hours (ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2693750/), could this slow decline be indicative of latent fibrin degradation?
It is advised to assess LVEF immediately prior to pertuzumab/trastuzumab initiation, every 3 months during pertuzumab/trastuzumab therapy, every 3 weeks if pertuzumab/trastuzumab is withheld for significant left ventricular cardiac dysfunction, and every 6 months for at least 2 years following completion of adjuvant pertuzumab/trastuzumab therapy. Pre-pertuzumab/trastuzumab 2D transthoracic echocardiography was performed on 2022-08-11, so it might be in need of updating. (Nov and Dec 2022 CXR showed borderline cardiomegaly and enlargement of cardiac silhouette.)
Since bilirubin total was 0.95 mg/dL on 2023-01-11, there is no need to adjust the dose of paclitaxel.
Over 15 kg of body weight have been lost in the past four months (41.2kg 2022-12-15 <- 55.8kg 2022-08-24). It is possible that the serum creatinine level remains below LLN since August 2022 as a result of insufficient dietary intake or muscle mass loss (malnutrition, muscle wasting). It should be necessary to encourage the patient to consume more food and there may be benefits to prescirbe megestrol as an appetite stimulant.
The presence of elevated plasma D-dimer concentrations indicates recent or ongoing intravascular coagulation and fibrinolysis. Although the reading remained high, it trended downward, a relatively positive sign. The metastatic liver lesion reduced clearance of fibrin degradation products?
According to the patient’s updated liver function lab results, paclitaxel dosage does not need to be adjusted.
[chemoimmunotherapy]
Trastuzumab and Pertuzumab, both monoclonal antibodies utilized in the management of HER2-positive breast cancer, can lead to several dermatologic side effects.
With Trastuzumab, patients may experience a skin rash in approximately 4% to 18% of cases.
Our dermatologist has prescribed Mycomb (nystatin, neomycin, gramicidin, triamcinolone) TOPI and Exelderm (sulconazole nitrate) EXT for the symptom on 2023-05-15.
In case of Grade 3 or higher paronychia - which is inflammation of the skin around the nails - the following approach is generally recommended aiming to manage the paronychia effectively while minimizing the impact on the patient’s overall cancer treatment plan. (ref: Prevention and management of dermatological toxicities related to anticancer agents: ESMO Clinical Practice Guidelines. Ann Oncol. 2021;32(2):157-170)
[diagnosis] - 2022-11-01 discharge note
[past history]
Type 2 diabetes mellitus, hyperlipidemia, and hypertension for 8 years under medications treatment and follow up at endocrinology & metabolism clinic.
History of operation:
[Current Medication] - 20230220 admission note
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Based on the PharmaCloud database, it appears that the patient has only been seen at our hospital for the past three months. No discrepancies or issues were identified in the medication reconciliation process for the patient upon admission this time.
The CT scan performed on 2023-01-20 showed no evidence of tumor recurrence. In addition, on 2023-05-03, both tumor markers, CEA and CA199, fell into the normal range for the first time. This is an encouraging development in the patient’s condition to date.
The patient experienced a severe eruption of pruritic papules and plaques over the trunk in early May 2023, probably in response to medication. The dermatologist has prescribed appropriate medications to treat this skin reaction. Please monitor closely for any recurrence of these symptoms.
The patient’s serum glucose levels have remained high, exceeding 270 mg/dL for the past two days. All medications prescribed by our endocrinologist have been added to the active formulary, and the patient is unwilling to take insulin injections. This makes appropriate dietary control even more important. It may be beneficial to schedule a consultation with a dietitian during the patient’s hospitalization to provide guidance on dietary changes to manage blood glucose levels.
All-RAS + BRAF + IHC results were like 700811991’s.
[consultation]
[chemotherapy]
[diagnosis] - 2023-04-09 admission note
[exam findings]
[MedRec]
[chemothereapy]
Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma 2023-05-22 https://www.uptodate.com/contents/image?imageKey=ONC%2F101205&topicKey=HEME%2F6647
[lab data]
prior to peripheral blood stem cell harvest
2023-04-17 CMV viral load assay Target not detecetedIU/mL
2023-04-17 EBV DNA quantitative amplification test <120
copies/mL
2023-04-13 EB VCA IgG Positive Ratio
2023-04-13 EB VCA IgG Value 5.3 Ratio
2023-04-12 EB VCA IgM Negative Index
2023-04-12 EB VCA IgM Value 0.0 Index
2023-04-10 RPR/VDRL Nonreactive
2023-04-10 CMV IgM Nonreactive
2023-04-10 CMV IgM Value 0.54 Index
2023-04-10 CMV_IgG Reactive
2023-04-10 CMV_IgG Value 834.1 AU/mL
2023-04-10 HIV Ab-EIA Nonreactive
2023-04-10 Anti-HIV Value 0.05 S/CO
2023-04-10 Anti-HBc Nonreactive
2023-04-10 Anti-HBc-Value 0.24 S/CO
2023-04-10 Anti-HCV Nonreactive
2023-04-10 Anti-HCV Value 0.06 S/CO
2023-04-10 HBsAg Nonreactive
2023-04-10 HBsAg (Value) 0.50 S/CO
2023-04-10 Anti HTLV I/II Nonreactive
2023-04-10 Anti HTLV I/II Value 0.05 S/CO
[lab data]
[exam findings]
[MedRec]
[consultation]
[assessment]
Dacogen (decitabine)
[past history]
Heart:(-)
Chest:(-)
Liver:(-)
Kidney:(-)
H/T:(-)
DM:(-)
Other medical:denied
Surgical: s/p Peripheral glioma excision 20+ years ago
Menstrual history: G4P2SA2, NSD x2
Menarche at the age of 13 years old
Menopaused at the age of 56 years old
Menstrual cycle:Duration/Interval:4days/28days
[allergy]
[family history]
[exam findings]
[surgical operation]
[chemotherapy]
2023-05-16 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 1000mL] IP 1hr
2023-04-25 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 1000mL] IP 1hr
2023-03-21 - liposome doxorubicin 35mg/m2 60mg D5W 250mL IP 90min + carboplatin AUC 5 600mg NS 250mL IP 90min (for HIPEC in operation)
2023-02-23 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1000mg NS 250mL 2hr
2023-01-31 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1000mg NS 250mL 2hr
2023-01-09 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1100mg NS 250mL 2hr
[assessment]
[exam findings]
[consultation]
[MedRec]
[chemotherapy]
[note]
Bortezomib (Velcade) plus cyclophosphamide and dexamethasone (VCD or CyBorD) for multiple myeloma 2023-04-24 https://www.uptodate.com/contents/image?topicKey=ONC%2F85687§ionRank=1&imageKey=ONC%2F50061
Cycle length: 28 days.
Regimen
Pretreatment considerations:
Monitoring parameters:
Suggested dose modifications for toxicity:
Treatment of Clostridioides difficile infection (CDI) in adults 2023-05-17 https://www.uptodate.com/contents/image?topicKey=ID%2F2698&imageKey=ID%2F53273
On 2023-05-14, the patient’s WBC was 7.37K/uL, creatinine was 1.01mg/dL, and stool occult blood was 2+. Stool culture obtained on 2023-05-15 was negative for Clostridioides difficile toxin A/B but positive for glutamate dehydrogenase (GDH). The patient had 9 and 8 bowel movements on 2023-05-15 and 2023-05-16, respectively. Therefore, the prescription of oral vancomycin at a dose of 125 mg 4 times daily is appropriate and unproblematic.
Now that the pathogen has been identified, the previously prescribed and currently active medication, Metrozole (metronidazole) 500mg PO Q8H, could potentially be discontinued, assuming there are no hypotension or shock, ileus, megacolon and/or other ongoing infectious conditions.
According to the HIS5 database, there have been no other culture reports on Clostridioides Difficile Infection (CDI) in the past 6 months. In the event of a recurrent infection, a tapered and pulsed regimen of vancomycin could be considered. Here is a possible schedule:
[assessment]
The patient has been diagnosed with Multiple Myeloma (MM) and was started on VCd regimen on 2023-01-03. All of the patient’s medications listed in PharmaCloud were prescribed by our hospital. No medication reconciliation issues were identified.
After starting the VCd regimen, there was a decrease in the B2 microglobulin level. However, the most recent reading indicates that the level has nearly doubled from the previous low in approximately 1.5 months.
Currently, there is no evidence that the patient is developing thrombocytopenia, peripheral neuropathy or neuropathic pain.
[exam findings]
[present illness] - 2023-02-23 admission note
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
[surigcal operation]
[radiotherapy]
[chemotherapy]
2023-04-25 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFOX)
2023-03-27 - fluorouracil 225mg/m2 430mg NS 100mL 10min D1-4 (CCRT)
2023-02-23 - fluorouracil 225mg/m2 430mg NS 100mL 10min D1, 2, 5, 7 (excluding weekend and 2/28 holiday) (CCRT)
According to the PharmaCloud database, all of the patient’s recent medications have been prescribed by our hospital, and no issues with medication reconciliation have been detected.
On 2023-05-15, the patient’s WBC count was observed to be 1.89K/uL, indicating leukopenia. This was first noted in the HIS5 system 3 weeks after the last administration of FOLFOX on 2023-04-25. When this event became known, Granocyte (lenograstim) was administered for two consecutive days. The nadir may occur later than expected, or blood cell monitoring should be more frequent.
This patient experienced hand-foot syndrome following the second dose of concurrent chemotherapy with 5-FU in late March 2023. The patient is currently undergoing FOLFOX treatment. If hand-foot syndrome reoccurs, it may be advisable to omit the 5-FU bolus.
The patient has underlying kidney concerns, and the NSAID Celebrex (celecoxib) is currently prescribed as needed. If the primary purpose of using celecoxib is for pain management, considering an alternative like acetaminophen could be less harmful to the kidneys.
[assessment]
{malignant neoplasm of unspecified site of left female breast, cT4aN3M1, stage IV}
[exam findings]
[surgical operation]
[chemoimmunotherapy]
[blood WBC]
[G-CSF]
[tube feeding]
As of 2023-05-12, the patient’s serum potassium level was measured at 3.2 mmol/L. Currently, Const-K is the only oral potassium supplement available in this hospital. If intravenous potassium supplementation is not the preferred method, it’s recommended to crush the Const-K tablet into small enough particles to pass through the feeding tube, and administer the supplement with sufficient water. It’s preferable to give this medication with meals due to its original extended-release design.
[past history]
Heart:(-)
Chest:(-)
Liver:(-)
Kidney:(-)
H/T:(-)
DM:(-)
Surgical:
Menstrual history: G2P2, menopause at age of 48
[allergy]
[family history]
[lab data]
2023-01-11 Anti-HBc Nonreactive
2023-01-11 Anti-HBc-Value 0.89 S/CO
2023-01-11 Anti-HBs 329.77 mIU/mL
2023-01-11 Anti-HCV Nonreactive
2023-01-11 Anti-HCV Value 0.07 S/CO
2023-01-11 HBsAg Nonreactive
2023-01-11 HBsAg (Value) 0.31 S/CO
[exam findings]
[consultation]
[MedRec]
[surgical operation]
[chemotherapy]
[assessment]
The PharmaCloud database reveals that the patient’s recent drugs have all been prescribed at our hospital. Currently, there are no issues detected with medication reconciliation in the active prescription.
The patient’s anemia, as evidenced by a decrease in hemoglobin level from 10.2 g/dL on 2023-05-02 to 8.1 g/dL on 2023-05-09, is currently being treated with a transfusion of 2 units of packed red blood cells (P-RBC), scheduled for 2023-05-11, as indicated.
The patient’s lab data reveals a decreasing trend in serum albumin levels, raising the possibility of a protein-losing gastroenteropathy. However, current records do not indicate the presence of edema, ascites or pleural and pericardial effusions. Furthermore, liver and kidney function appear to be within or not far from normal ranges based on the lab data, suggesting that heavy proteinuria or impaired protein synthesis due to liver disease are less likely causes. It is recommended to encourage the patient to pay more attention to nutritional supplementation to prevent malnutrition.
Intestinal leakage of plasma proteins occurs via one of the following mechanisms:
The CT scan on 2023-04-22 revealed recurrent tumors in the pelvic cavity measuring 4.7cm and 7.9cm, respectively. These tumors have invaded adjacent structures, causing right hydronephrosis and hydroureter, and lymph nodes are also evident in the retroperitoneum. These findings might be related to the observed clinical phenomena mentioned above?
[assessment]
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
Please be aware that the patient’s renal function has been declining over the past three days. At present, there’s no need for a dose adjustment, but it’s crucial to continue monitoring closely.
Lab data has shown signs of recovery in the patient’s WBC count. However, the PLT count continues to hover at relatively low levels, never reaching 100K/uL.
Indications for platelet transfusion include actively bleeding patients with thrombocytopenia who should receive immediate platelet transfusion to maintain platelet counts above 50K/uL in most bleeding situations, including disseminated intravascular coagulation (DIC), and above 100K/uL in central nervous system bleeding.
Unfortunately, there are no perfect tests to predict spontaneous bleeding. Studies in patients with thrombocytopenia suggest that spontaneous bleeding can occur even with platelet counts above 50K/uL. However, bleeding is much more likely when the platelet count falls below 5K/uL. For individuals with platelet counts between 5K and 50K/uL, clinical observations may be useful in deciding whether to transfuse platelets.
[diagnosis] - 2023-05-08 admission note
[MedRec]
[radiotherapy]
[chemotherapy]
[assessment]
[diagnosis] - 2023-03-23 admission note
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
{not completed}
[MedRec]
[chemotherapy]
[assessment]
[MedRec]
[chemotherapy]
[assessment]
[lab data]
[exam findings]
[consultation]
[MedRec]
[radiotherapy]
[chemotherapy]
[tube feeding]
Nexium (esomeprazole) should not be crushed. Instead, it should be dissolved in sufficient drinking water before tube feeding.
[tube feeding]
[tube feeding]
[diagnosis] - 2023-05-07 admission note
[present illness]
[past history] - 2023-05-07 admission note
[family history]
[lab data]
[exam findings]
[consultation]
[MedRec]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
From 2022-11-21 to 2023-01-09, the patient was treated with Avastin plus FOLFOX for his K-RAS-mutated sigmoid colon adenocarcinoma. However, a CT scan on 2022-12-02 showed progressive disease with multiple liver and lung metastases, as well as metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space. As a result, the regimen was changed to Avastin plus FOLFIRI on 2023-01-27. Due to dizziness and headache experienced during chemotherapy on 2023-03-01, the fluorouracil dose was reduced by half starting on 2023-03-21.
After the new regimen was applied, the tumor marker CEA has remained relatively unchanged; however, the readings are approximately twice as high as they were before.
The Covid-19 fast screen was positive on 2023-04-24, but the patient has since recovered. Vital signs are currently stable. CT and CXR revealed lung mets with multiple nodular opacities in both lungs, which do not significantly impair the patient’s respiratory function yet.
The underlying conditions are currently being managed with appropriate medications: anemia is treated with Foliromin (ferrous sodium citrate), toe numbness is treated with Kentamin (B1, B6, B12), right upper quadrant abdominal and rib area pain is treated with Tramacet (tramadol, acetaminophen) and Neurontin (gabapentin), respiratory symptoms are treated with Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), oral candidiasis is treated with Mycostatin (nystatin), and intermittent diarrhea is managed with loperamide and Smecta (dioctahedral smectite) as needed (PRN).
[drug interaction]
The ability of oral iron preparations to reduce the absorption of oral quinolones is well established and has been demonstrated in numerous pharmacokinetic studies. Various oral iron preparations have been reported to reduce quinolone AUCs by the following percentages: ciprofloxacin (33% to 70%), levofloxacin (19%), lomefloxacin (14%), moxifloxacin (61%), norfloxacin (51% to 73%), ofloxacin (25%), and sparfloxacin (28%). The maximum serum concentrations of oral quinolones were reduced by the following percentages: ciprofloxacin (46% to 75%), levofloxacin (45%), lomefloxacin (28%), moxifloxacin (41%), norfloxacin (75% to 82%), ofloxacin (36%), and sparfloxacin (46%). It is recommended to administer oral quinolones at least several hours before (4 h for moxifloxacin and sparfloxacin, 2 h for others) or after (8 h for moxifloxacin, 6 h for ciprofloxacin and delafloxacin, 4 h for lomefloxacin, 3 h for gemifloxacin, 2 h for enoxacin, levofloxacin, norfloxacin, ofloxacin, pefloxacin, or nalidixic acid) oral iron preparations.
Due to the fact that Cravit (levofloxacin) and Foliromin (ferrous sodium citrate) were prescribed as QDAC and BID, respectively. To maintain Cravit’s effectiveness, Foliromin might be moved to QL and QN.
Please monitor for diminished effects of the quinolone if dose separation cannot be achieved.
[diagnosis] - 2023-04-26 admision note
[past history] - 2023-04-26 admision note
[allergy]
[family history]
[exam findings]
[lab data]
[consultation]
[MedRec]
On 2023-05-08 at 06:05, the patient’s SpO2 dropped to 69%, accompanied by an increased heart rate of 100 bpm. This indicates possible respiratory distress or compromised oxygenation, and an O2 mask is placed appropriately.
If the patient continues to experience hemoptysis, inhaled tranexamic acid could be considered as a potential treatment option to reduce bleeding. This antifibrinolytic agent has been shown to effectively control bleeding and may provide relief to the patient.
[exam findings]
[consultation]
[surgical operation]
2022-02-11 MWA, Microwave ablation
2021-09-27 VATS, decortication
2021-03-29 VATS, LUL and LLL wedges resection for metastasectomy + pneumolysis
2021-09-16 RFA, Radiofrequency Ablation
2021-08-19 RFA, Radiofrequency Ablation
2020-07-01 3D VATS RUL, RML and RLL wedge resections + LND. decortication
2018-03-29 laparoscopic lower anterior resection w/ TaTME and S3, S8 subsegmentectomy + S5 cyst unroofing (Taipei Veterans General Hospital)
[radiotherapy]
[chemoimmunotherapy]
[note]
FOLFOXIRI chemotherapy for metastatic colorectal cancer 2023-04-25 https://www.uptodate.com/contents/image?topicKey=ONC%2F2503&imageKey=ONC%2F70559
Cycle length: 14 days.
Regimen
Pretreatment considerations:
Monitoring parameters:
Suggested dose modifications for toxicity (The specific dose alteration parameters for the FOLFOXIRI regimen in colorectal cancer patients were not published in the original phase III trial. The following suggestions are based upon dose reductions used in a trial using a comparable regimen (FOLFIRINOX) for advanced pancreatic cancer.)
[tube feeding]
{not completed}
[MedRec]
[exam findings]
[assessment - not posted]
[exam findings]
[MedRec]
[chemoimmunotherapy]
[assessment]
{not completed}
[MedRec]
[surgical operation]
[medication]
2023-03-15 ~ 2023-03-29 - UFT (tegafur 100mg, uracil 224mg) 2# BID
2022-02-08 ~ 2022-04-25 - TS-1 (tegafur, gimeracil, oteracil) 2# BID
2021-09-09 ~ 2021-10-15 - Xeloda (capecitabine 500mg) 2# BID
B-Red (hydroxocobalamin 1mg)
[diagnosis] - 2023-03-22 SOAP
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[chemotherapy]
[note]
hyperbilirubinemia - ref: 2023-05-05 UpToDate
CA199, CEA - ref: 2023-05-05 ChatGPT
Nab-paclitaxel and gemcitabine treatment was first initiated on 2023-03-27 and is currently ongoing. The 3rd dose was administered on 2023-04-24 with a 20% reduction in dosage due to dizziness, nausea, and vomiting. The patient also experienced conscious disturbance and abdominal fullness, which led to ascites tapping on 2023-05-02.
After receiving 3 doses of the regimen, the patient’s tumor marker CA199 remains relatively unchanged, while there is a significant increase in CEA levels.
The TPR panel indicated no bowel movement on 2023-05-03 and 2023-05-04. It is suggested to assess whether the patient has developed constipation, as bisacodyl is prescribed as needed (PRN) for this issue.
[tube feeding]
As of 2023-05-01, the patient’s serum potassium level has returned to the normal range of 3.5 mmol/L. However, the current prescription for Const-K will expire on 2023-05-04, and it may be worth considering discontinuing this medication. It should be noted that the potassium content of fruits is relatively low (for example, about 2.2 mEq/inch or 0.9 mEq/cm in bananas), meaning that it would take about two to three bananas to provide 40 mEq. Const-K is an extended-release formulation containing 10 mEq/tab, which is less potassium than is found in one banana. If injectable potassium supplementation is not preferred (Const-K remains the only oral potassium supplement available today), please crush the tablet into particles and administer it with water.
For patients who have difficulty swallowing Protase (pancrelipase) capsules, the capsule can be opened and the enteric-coated granules can be released into a small amount of liquid food with a pH not exceeding 5.5. Tube feed the drug particles with drinking water or juice to ensure complete ingestion.
As for Megejohn (megestrol acetate), since our hospital has Megest (megestrol 40mg/mL, 120mL/bot) in stock, it is suggested to switch Megejohn to the Megest oral suspension.
[exam findings]
[MedRec]
[radiotherapy]
[chemotherapy]
2023-05-04 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4555mg NS 250mL 46hr (FOLFIRI)
2023-04-07 (FOLFIRI)
2023-03-22 (FOLFIRI)
2023-03-08 (FOLFIRI)
2023-02-22 (FOLFIRI)
2022-02-23 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX)
2022-02-09 (FOLFOX)
2022-01-26 (FOLFOX)
2022-01-12 (FOLFOX)
2021-12-29 (FOLFOX)
2021-12-15 (FOLFOX)
2021-12-01 (FOLFOX)
2021-11-17 (FOLFOX)
2021-11-03 (FOLFOX)
2021-10-20 (FOLFOX)
2021-10-01 (FOLFOX)
2021-09-09 (FOLFOX)
[assessment]
No medication reconciliation issues have been identified for this patient.
The patient appears to be tolerating the current regimen well, and his labs are mostly within normal ranges, with the exception of slightly elevated liver function tests and BUN.
[allergy]
[family history]
[exam findings]
[consultation]
[MedRec]
[diagnosis] - 2023-05-06 discharge note
[MedRec]
[chemotherapy]
[assessment]
[exam findings]
[assessment]
Hyperleukocytosis (leukostasis) was confirmed by laboratory tests, and the patient has been treated with Hydrea (hydroxyurea 500mg) 2# TID since 2023-05-03, which has helped to control the high WBC count.
Leukostasis can be diagnosed when a biopsy of affected tissue shows white cell clots in the microvasculature (2023-05-02 CT: suspected splenic infarct). Please be aware of possible clinical signs of leukostasis, such as
Feburic (febuxostat) is used as prophylaxis for potential tumor lysis syndrome. Lab data show that elevated serum uric acid levels have returned to normal following administration of the drug.
Caution should be exercised when using intravenous contrast at a time when renal function may be compromised by leukostasis or tumor lysis syndrome and dehydration. (2023-05-04 BUN 29mg/dL, Cre 1.10mg/dL, eGFR 70.75, normal values in K. The patient is currently hydrated with NS 500mL BID. No apparent renal insufficiency at this time).
[lab data]
[exam findings]
[MedRec]
[note]
FOLFIRINOX chemotherapy for metastatic pancreatic cancer 2023-05-04 https://www.uptodate.com/contents/image?topicKey=ONC%2F2475&imageKey=ONC%2F79571
[chemotherapy]
[assessment]
This is the first time the patient has received FOLFIRINOX chemotherapy for his pancreatic cancer, with a reduced dose of irinotecan (180mg/m2 reduced to 120mg/m2) and oxaliplatin (85mg/m2 reduced to 65mg/m2). Thus far, no significant adverse reactions have been observed.
2023-05-03 Anti-HBc Reactive
2023-05-03 Anti-HBc-Value 8.55 S/CO
[diagnosis] - 2023-05-02 admission note
[exam findings]
[consultation]
[MedRec]
[surgical operation]
[chemoimmunotherapy]
[assessment]
The patient was diagnosed with gastric adenocarcinoma, pT4aN1M0 stage IIIA in July 2022. Total gastrectomy with lymphadenectomy was performed on 2022-09-05, followed by FOLFOX treatment starting on 2022-10-05.
A CT scan on 2022-11-28 showed liver metastases in progression, and a PET scan on 2022-12-26 revealed that the gastric cancer had progressed, with suspected regional lymph nodes and liver metastases, cTxN2M1, stage IVB. After receiving six doses of FOLFOX (with the last dose administered on 2022-12-23), the patient’s regimen was changed to FOLFIRI starting on 2023-01-12.
The patient was admitted to the hospital for his 6th dose of FOLFIRI (trastuzumab was added to the regimen since 2023-04-07, making this the 2nd dose). The patient tolerates the regimen well, and no significant adverse reactions have been observed.
After partial or total gastrectomy, the availability of gastric acid and intrinsic factor, both essential for vitamin B12 absorption, is reduced or eliminated. As a result, individuals who have undergone partial or total gastrectomy would benefit from supplementing their diet with oral vitamin B12 or receiving intramuscular or subcutaneous injections of vitamin B12. B-Red (hydroxocobalamin) is appropriately administered as a daily supplement for this patient.
The patient’s underlying condition of chronic viral hepatitis B is appropriately treated with Baraclude (entecavir).
A review of the PharmaCloud database reveals that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.
The patient was proved with gastric adenocarcinoma, pT4aN1M0 stage IIIA in July 2022. Total gastrectomy with lymphadenectomy was performed on 2022-09-05 then FOLFOX was applied since 2022-10-05.
2022-11-28 CT showed liver mets in progression and 2022-12-26 PET showed the gastric cancer progressed with suspected regional lymph nodes and liver mets, cTxN2M1, stage IVB. After administration of 6 times of FOLFOX (last dose on 2022-12-23), then the regimen changed to FOLFIRI since 2023-01-12.
The patient admitted this hospitalization for his 6th dose of FOLFIRI (trastuzumab was added to the regimen since 2023-04-07, this time the 2nd dose). The patient tolerates the regimen well and no obvious adverse reaction is found.
The PharmaCloud database shows that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.
[diagnosis]
[past history]
[family history]
[exam findings]
[chemotherapy]
On 2022-10-07, 2023-01-05, and 2023-04-29, CT scans demonstrated disease progression, with the most recent scan also revealing possible liver metastases. This information highlights the need for close monitoring and potentially re-evaluating the patient’s treatment plan.
The patient’s renal function improved according to the most recent lab values.
If the initial consideration for reducing the dose of topotecan was due to the patient’s inadequate renal function, this reason becomes less important. However, the patient also experienced leukopenia and thrombocytopenia after the standard dose of 1.5 mg/m2 topotecan in January 2023. The full standard dose may potentially lead to episodes of leukopenia and/or thrombocytopenia. A moderate titration to 0.9 or 1.0 mg/m2 from 0.75mg/m2 could be considered as a feasible option to balance treatment efficacy and side effect profile if the same regimen is intended to be continued.
This patient has a tendency to develop leukopenia and/or thrombocytopenia after receiving the normal dose of 1.5mg/m2 topotecan. However, after the dose was reduced to 0.75mg/m2, no further high-grade adverse reactions were observed.
2023-03-02 WBC 5.87 x10^3/uL
2023-02-23 WBC 12.24 x10^3/uL
2023-02-16 WBC 3.07 x10^3/uL
2023-02-13 WBC 4.44 x10^3/uL
2023-02-09 WBC 22.96 x10^3/uL
2023-02-06 WBC 2.70 x10^3/uL
2023-02-03 WBC 2.09 x10^3/uL
2023-02-01 WBC 2.32 x10^3/uL
2023-01-30 WBC 1.66 x10^3/uL
2023-01-27 WBC 0.71 x10^3/uL
2023-01-26 WBC 0.70 x10^3/uL
2023-01-22 WBC 2.41 x10^3/uL
2023-01-16 WBC 5.05 x10^3/uL
2023-03-02 PLT 234 x10^3/uL
2023-02-23 PLT 109 x10^3/uL
2023-02-16 PLT 275 x10^3/uL
2023-02-13 PLT 308 x10^3/uL
2023-02-09 PLT 270 x10^3/uL
2023-02-06 PLT 123 x10^3/uL
2023-02-03 PLT 65 x10^3/uL
2023-02-01 PLT 47 x10^3/uL
2023-01-30 PLT 50 x10^3/uL
2023-01-27 PLT 154 x10^3/uL
2023-01-26 PLT 38 x10^3/uL
2023-01-22 PLT 155 x10^3/uL
2023-01-16 PLT 312 x10^3/uL
S2021-11516A9 (renal pelvic cancer) 2023-01-27 PD-L1 IHC lab results:
PD-L1 expression is not high, suggesting that certain PD-L1 targeted drugs are less likely to be effective against the tumor.
In light of the patient’s diarrhea episodes last month, please keep an eye on her bowel movements. Topotecan is associated with nausea (grade 3/4 8-10%), diarrhea (grade 3/4 6%), and vomiting (grade 3/4 10%). Since the administration days and daily dose of topotecan have been reduced (1.5mg/m2 -> 0.75m2/m2; 5 days -> 3 days), the adverse reaction should be mitigated. As well, Smecta (dioctahedral smectite) 3mg PO PRNTIDAC has been prescribed.
[diagnosis] - 2023-04-27 admission note
[exam findings]
[consultation]
[MedRec]
[surgical operation]
[chemotherapy]
2023-04-21 - docetaxel 30mg/m2 38mg D5W 250mL 1hr + leucovorin 200mg/m2 250mg NS 250mL 2hr + fluorouracil 2000mg/m2 2515mg NS 500mL 24hr + [paclitaxel 20mg NS 1000mL + gentamicin 40mg + sodium bicarbonate 4200mg] IP 1hr (NIPS)
2023-02-14 - oxaliplatin 130mg/m2 150mg D5W 250mL 2hr + [paclitaxel 20mg NS 1000mL + gentamicin 40mg + sodium bicarbonate 2800mg] (with 2023-02-16 ~ 2023-03-14 oral capecitabine)
2023-01-12 - [oxaliplatin 400mg + paclitaxel 120mg + D5W 2500mL] IP 90min
Xeloda (capecitabine 500mg) KXEL)01
[assessment]
Significant weight loss has been observed in the patient, from 43.5kg on 2023-01-06 to 33.3kg on 2023-04-27. Megestrol has been prescribed intermittently between late Dec 2022 and late Feb 2023. If the patient can still tolerate oral intake and there are no contraindications, it may be beneficial to consider adding megestrol back into the patient’s treatment plan to help increase appetite and promote weight gain.
Additionally, providing nutritional support and guidance, including a consultation with a dietician, may further assist in addressing the patient’s weight loss.
The patient has had 7 episodes of diarrhea since 2023-04-26, as noted in the admission record. It is recommended that the number of bowel movements be included in the TPR panel along with the I/O data. If the symptom persists, the addition of loperamide may be beneficial in the management of diarrhea.
Both docetaxel and fluorouracil are associated with diarrhea as a side effect. If diarrhea is suspected to be more related to fluorouracil (2000mg/m2 D1), reducing the dose of fluorouracil (70~80% of the intended dose) at the next treatment may be an option to consider.
[exam findings]
[MedRec]
[chemoimmunotherapy]
[Trimethoprim/Sulfamethoxazole (TMP/SMX) dosing]
Trimethoprim/sulfamethoxazole(TMP/SMX) for patients with moderate to severe Pneumocystis pneumonia infection: IV 15 to 20 mg/kg/day (TMP component) in 3 or 4 divided doses; may switch to oral therapy after clinical improvement.
As recent lab results revealed no abnormalities in the liver and kidney functions, it is less likely that dosage adjustments will be needed.
Patients with moderate or severe infection (PaO2 <70 mm Hg at room air or alveolar-arterial oxygen gradient >= 35 mm Hg) should receive adjunctive glucocorticoids.
{not completed}
[exam findings] (not completed)
[consultation]
[assessment]
AKuriT-4 (RIF 150mg + INH 75mg + PZA 400mg + EMB 275mg) 3# PO QDAC is administered according to the patient’s bone tuberculosis.
It is important to note that the patient is currently taking multiple NSAIDs (Laston (ketorolac) ST, Celebrex (celecoxib) QD, naproxen PRNQ8H). Concomitant use of multiple NSAIDs is not recommended due to the increased risk of side effects such as bleeding and kidney damage. Please monitor the patient closely for signs of bleeding or changes in kidney function and consider adjusting her medication regimen if necessary.
[diagnosis] - 2023-03-29 admission note
[past history] - 2023-03-06 admission note
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
2023-04-26 lab results showed low serum Na (133 mmol/L), K (3.4 mmol/L), Mg (1.4 mg/dL), and albumin (3.3 g/dL). These electrolyte imbalances are currently being addressed with appropriate supplementation. With the exception of mild anemia, the patient’s blood cell counts are within normal limits and do not represent a contraindication to the planned chemotherapy.
The PharmaCloud database shows that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.
Laboratory data on 2023-03-29 showed normal liver/kidney function, however, cation electrolytes and HGB were slightly decreased, which would not contraindicate the planned chemotherapy.
Ascites cytology on 2023-03-08, 2023-03-07, 2023-02-20, 2023-02-17 showed no evidence of positive results.
No medication reconciliation issue identified.
{not completed}
[exam findings]
[surgical operation]
[chemotherapy]
Medication
[assessment]
[past history] - 2023-04-20 admission note
Hypertension for 10 years with regular medication control.
DM with triopathy for 10+ years with regular OHA, insulin control.
Asthma: Asthma since young with regular OPD f/u.
Operation history: Appendectomy 10 yrs ago.
Denied history of Hypertension, DM, asthma
Denied any operation, accident and other medical Hx.
[allergy]
[family history]
[exam findings]
[consultation]
[lab data]
[MedRec]
[assessment]
The patient was diagnosed with rectosigmoid cancer and underwent sigmoidectomy followed by treatment with the FOLFOX regimen in 2020. However, the patient experienced progressive disease. Laparoscopic plevic LND was performed in March 2022, and the patient was subsequently treated with the A-FOLFIRI regimen, but again experienced PD. This time, the patient was admitted to receive the planned FOLFOXIRI regimen.
Flumarin (flomoxef sodium) has been administered since 2023-04-23 to address the elevated sediment WBC and leukocyte esterase in the patient’s urine without issues.
The patient’s platelet count (PLT) has been decreasing over the past three years, with levels not exceeding 100K/uL in 2023. This should be carefully monitored, as it may suggest the presence of undiagnosed underlying conditions that require further evaluation and management.
[diagnosis] - 2023-04-25 admission note
[past history] - 2023-04-25 admission note
DM, HTN, CHF, COPD, Hyperlipidemia, Asthma
[allergy]
[family history]
no hypertension, diabetes mellitus, cancer history
[exam finding]
[consultation]
[MedRec]
[chemoimmunotherapy]
[note]
There is no medication reconciliation issue for the current active formulary, which includes medications prescribed by our cardiologist, pulmonologist, and metabolic specialist.
The patient’s underlying conditions of hypertension (HTN) and type 2 diabetes mellitus (T2DM) are not well controlled during this hospitalization. Blood pressure readings show systolic values between 170 and 184 mmHg, and HbA1c levels have been consistently above 8% for the past 4 months. Serum glucose was recorded as 231mg/dL on the evening of 2023-04-25 and as 158mg/dL on the morning of 2023-04-26. Addition of antihypertensive and/or hypoglycemic agents may be considered if symptoms persist.
[exam findings] (not completed)
[consultation]
[chemotherapy]
2022-09-27 - doxorubicin 60mg/m2 85mg NS 100mL 10min
2022-08-30
2022-08-01
2022-07-01
2022-05-31
2022-01-03 - cisplatin 100mg/m2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1550mg NS 500mL 21hr
2021-11-12 - NS 500mL (before cisplatin) + cisplatin 30mg/m2 40mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)
2021-11-05
2021-10-29
2021-05-11
2021-05-04
2021-04-28
2020-11-03
2020-10-27
2020-10-20
[assessment]
On 2023-04-03, a PET scan revealed multiple glucose hypermetabolic lesions in the right supra-renal region, right paraaortic space, bilateral common iliac chains, and soft tissue in the right lower quadrant (RLQ) of the abdomen. These lesions could indicate metastatic disease progression or even another primary malignancy. A CT-guided biopsy of the soft tissue mass in the right lower quadrant of the abdomen is scheduled for 2023-04-25 at 11:00 AM to determine the nature of these lesions.
2023-04-24 eGFR 46. OxyNorm (oxycodone) - CrCl 30 to <60 mL/minute: Immediate release, Oral: Initial: Administer 50% to 75% of usual dose no more frequently than every 6 hours. Use with caution; titrate gradually based on patient response and adverse effects.
[exam findings]
[consultation]
[MedRec]
[diagnosis] - 2023-04-22 discharge note
[exam findings]
2023-03-11 Anoscopy
2023-02-09 2D transthoracic echocardiography
2022-12-22 Nasopharyngoscopy
2022-11-24 2D transthoracic echocardiography
2022-11-17 SONO - abdomen
2022-10-26 PET scan
2022-10-18 Patho - breast mastectomy with regional lymph nodes
2022-10-18 Frozen Section
2022-10-17 Flow Volume Loop
2022-10-07 Patho - breast biopsy (no need margin)
2022-10-07 SONO - breast
2022-10-07 Mammography
2022-08-25 SONO - abdomen
2022-08-11 Nasopharyngoscopy
2022-06-30 ENT Hearing Test
2022-06-08 Neurosonology
2022-06-02 SONO - abdomen
……
……
2017-05-26 Surgical pathology Level VI
2017-05-25 PET scan
2017-05-22 Gynecologic ultrasonography
2017-05-16 Surgical pathology Level IV
2017-05-16 SONO - breast
[consultation]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
2023-04-21 - docetaxel 75mg/m2 110mg NS 250mL 1hr
2023-03-31 - docetaxel 75mg/m2 111mg NS 250mL 1hr
2023-03-10 - docetaxel 75mg/m2 108mg NS 250mL 1hr
2023-03-02 - docetaxel DC (due to WBC 1.57K/uL)
2023-02-09 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 866mg NS 500mL 1hr
2023-01-18 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr
2022-12-21 - liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 988mg NS 500mL 1hr (2023-01-11 WBC 1.67K/uL)
2022-11-29 - liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 864mg NS 500mL 1hr
Femara (letrozole) KFEMA01
Granocyte (lenograstim) CGRAN01
Foliromin (ferrous sodium citrate) KFOLIR01
The patient’s HGB levels show a marked downward trend, even though there is no record of blood transfusion. With recent MCV and MCH levels both above the normal range, this macrocytic anemia is less likely to be caused by iron deficiency. The addition of oral Kentamine (vitamin B1, B6, B12) may be helpful.
The development of anemia during chemotherapy suggests that the patient’s HGB levels are not fully recovered at the current dosage, interval, and frequency of the treatment regimen. In cases of severe chemotherapy-induced anemia, blood transfusion is recommended. Another potential option could be to reduce docetaxel from 75mg/m2 to 65mg/m2.
If the patient refuses a blood transfusion, a less optimal alternative may be the use of erythropoiesis-stimulating agents (ESAs). However, it is important to note that ESAs have been associated with shorter overall survival and/or increased risk of tumor progression or recurrence in clinical trials involving patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers. To minimize these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, the lowest effective dose should be used to avoid red blood cell transfusions. ESAs should only be used for anemia resulting from myelosuppressive chemotherapy and are not indicated for patients receiving myelosuppressive chemotherapy when the expected outcome is cure. It is also recommended that ESAs be discontinued after completion of chemotherapy.
On 2022-10-28, the multidisciplinary cancer team held a meeting and decided on the following treatment plan for the patient: TC chemotherapy every three weeks for a total of 4 cycles, followed by a CDK4/6 inhibitor (patient self-paid), radiotherapy, and 5 years of hormone therapy.
The patient received 4 cycles of AC (liposome doxorubicin plus cyclophosphamide) on 2022-11-29, 2022-12-21, 2023-01-18, and 2023-02-09. On 2023-01-11, leukopenia occurred with a WBC count of 1.67K/uL, leading to a reduction in liposome doxorubicin dosage from 35mg/m2 to 30mg/m2 for the last two cycles. On 2023-03-02, another leukopenia episode was observed with a WBC count of 1.57K/uL, causing the scheduled docetaxel on that day to be postponed.
The patient’s HGB and PLT levels are showing a obvious decline trend, despite no record of blood transfusion being available. This suggests that under the current dose, interval, and frequency of administration, the patient’s HGB and PLT levels are not able to fully recover.
When severe anemia caused by chemotherapy is present, blood transfusion is recommended. However, if the patient refuses to receive transfusion, a suboptimal option could be to use erythropoiesis-stimulating agents (ESAs). It is important to note that ESAs have been associated with a shortened overall survival and/or an increased risk of tumor progression or recurrence in clinical studies of patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers. To decrease these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, the lowest effective dose should be used to avoid RBC transfusions. ESAs should only be used for anemia from myelosuppressive chemotherapy and are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure. It is also suggested to discontinue ESAs following the completion of a chemotherapy course.
[diagnosis] - 2023-03-22 admissiion note
[past history]
The patient had no systemic diseases
History of operation: NIL
Regular medications or herb: no
G2P2
menarche : 16y/o
menopause: 51y/o
Hormone therapy: (-)
Family history of breast cancar: NIL
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
[note]
in-hospital “Prescription Collection of Chemotherapy for Breast Cancer” protocol (dated 2022-03-11)
{not completed}
[diagnosis] - 2023-04-21 discharge note
[exam findings]
[lab data]
2021-09-23 EGFR Sample No S21-11584
2021-09-23 EGFR G719X not detected
2021-09-23 EGFR Exon19 del not detected
2021-09-23 EGFR S768I not detected
2021-09-23 EGFR T790M not detected
2021-09-23 EGFR Exon20 ins not detected
2021-09-23 EGFR L858R detected
2021-09-23 EGFR L861Q not detected
[MedRec]
[medication]
[diagnosis] - 2023-04-13 admission note
[present illness] - 2023-04-13 admission note
[past history]
[allergy]
[family history]
1.There is no family history of cancer, hypertension, mental diseases or asthma. 2.No members of the family with diabetes.
[lab data]
2023-04-17 Anti-HCV Nonreactive
2023-04-17 Anti-HCV Value 0.10 S/CO
2023-04-17 Anti-HBc Reactive
2023-04-17 Anti-HBc-Value 4.11 S/CO
2023-04-17 Anti-HBs 774.10 mIU/mL
2023-04-17 HBsAg Nonreactive
2023-04-17 HBsAg (Value) 0.40 S/CO
[chemotherapy]
[assessment]
[exam findings]
[SOAP]
[assessment]
The patient should have been diagnosed with dyslipidemia and hypertension with heart failure, as he has regularly refilled prescriptions for rosuvastatin, valsartan, and spironolactone within the past 3 months, according to PharmaCloud. Additionally, a CT scan on 2023-04-03 revealed extensive 3-vessel coronary artery disease (3V-CAD), indicating significant atherosclerotic plaque in the LAD, LCX, and RCA.
If there are no contraindications, it is recommended to reintroduce these medications and consult a cardiologist to assess whether the patient requires aggressive medical management or revascularization procedures, such as coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI angioplasty with stent placement).
[chief complaint] - 2023-04-17 admission note
[present illness] - 2023-04-17 admission note
The 57 y/o woman has history of hypertension. She had fall down in bus on 2022/11 and then fatigue, vertigo and right hip pain since 2023/01/07, so she bedridden for 3 months. Right breast tumor noted also 3 months. This time, she has dizziness and severe vertigo, so she was brought to our ED for help on 2023/04/17. Her right lower limbs MP down to 3 for 3 months. She denied fever, chills, vomit, SOB or hematuria. At ED, the brain CT showed 1. Mild cortical brain atrophy. 2. Left parietal skull osteolytic destruction, metastasis or less likely arachnoid granulation? 3. Chronic left mastoiditis. UTI noted from urinalysis. Under the impression of right breast tumor, vertigo, suspect spinal stenosis, so she was admitted on 2023/04/17.
[past history]
[allergy]
[family history]
[exam findings]
[SOAP]
[assessment]
[diagnosis] - 2023-04-12 admission note
[past history]
[family history]
[lab data]
[exam findings]
[surgical operation]
[chemotherapy]
[past history] - 2023-04-13 admission note
OB/GYN history:
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[assessment]
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
[assessment]
{not completed}
[exam findings]
[consultation]
[chemotherapy]
UFT (tegafur 100mg + Uracil 224mg) KUFT01
[assessment]
[exam findings]
[chemotherapy]
[assessment]
The patient’s serum creatinine has been above 2 mg/dL since 2022Q4 and has not dropped below that level since. The eGFR has been consistently around 30 since 2023.
On 2023-04-13 the following lab results were obtained: HGB 5.1g/dL, Iron bound Fe 22ug/dL, UIBC 145ug/dL, TIBC 146ug/dL, AST 14U/L, and ALT 13U/L. On 2023-04-14, Ferritin was 545ng/mL and Transferrin was 124ng/mL. There is no evidence of iron deficiency or liver dysfunction. Anemia of chronic disease and/or anemia of inflammation might be possible, as well as nutritionally deficiency. The body weight of 36.5 kg recorded on the TPR panel on 2023-04-13 appears to be too low, which may be an erroneous entry.
[diagnosis] - 2022-11-25 admission note
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[chemotherapy]
His blood lab data indicated that his ferritin level increased by over 30% in less than 20 days after taking iron supplements from time to time.
High ferritin levels suggest an excess of iron or an acute inflammatory reaction in which ferritin is mobilized without excess iron. Ferritin can be used as an indicator of iron overload disorders, such as hemochromatosis or hemosiderosis. Ferritin can increase the liver proinflammatory mediators IL-1b, iNOS, RANTES, IkappaB alpha, and ICAM1. As ferritin is also an acute-phase reactant, it is often elevated in various diseases. A normal C-reactive protein (CRP) can be used to exclude elevated ferritin caused by acute phase reactions. However, our HIS5 does not contain simultaneous data on ferritin levels and CRP levels.
As the body content of iron (iron burden) increases beyond that needed for normal production of red blood cells, muscle cells, and iron-containing enzymes, the plasma iron-binding protein transferrin becomes saturated, eventually exceeding its capacity and resulting in binding of iron to other proteins and molecules, including albumin, citrate, acetate, and others. This iron is referred to as non-transferrin-bound iron (NTBI); it begins to appear once the transferrin saturation exceeds 35 percent and rises significantly with transferrin saturation above 70 percent. NTBI is taken up by cells that have active uptake mechanisms. This includes parenchymal cells of the liver, heart, and endocrine organs. In these affected organs, excess iron can chemically interact with hydrogen peroxide. These reactive oxygen species in turn can cause tissue damage, inflammation, and fibrosis. The liver, heart, joints, and endocrine organs appear to be especially susceptible.
By the time clinical findings have developed (hepatic fibrosis, heart failure, cardiac conduction defect), it is likely that significant iron deposition and tissue injury has occurred. Please ensure that the patient’s iron level is checked as needed and monitor any signs of iron overload if iron supplements are continued.
The lab data indicated that MCV, MCH, MCHC, UIBC were normal; Ferritin was exceeded; Fe (iron bound) and TIBC was low.
Normal MCV, MCH, MCHC may suggest the anemia is less likely to be caused by iron insufficiency. High ferritin may suggest iron overload. Low TIBC can suggest that there is not enough transferrin available to bind to iron, i.e., the patient has high iron level, so most of the transferrin is bound to it, which leaves very little free in his blood. Frequent blood transfusions may cause iron overload.
It is recommended to hold the Foliromin (ferrous sodium citrate) until the cause of the anemia is confirmed to be iron deficiency.
[diagnosis] - 2023-04-06 admission note
[past history] - 2023-04-06 admission note
[allergy]
[family history]
[exam findings]
[consultation]
[SOAP]
[surgical operation]
[chemoimmunotherapy]
2023-03-30 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 + oxaliplatin 100mg/m2 150mg D5W 250mL 2hr D2 (R-GemOx)
2023-02-21 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2023-01-27 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2023-01-13 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)
2023-01-06 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)
2022-12-29 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)
2022-12-05 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2022-11-14 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2022-10-13 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2022-09-22 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2022-08-19 - rituximab 375mg/m2 630mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-COP)
Tramadol has been associated with vomiting (5% to 10%). ref: UpToDate.
Opioid administration can induce nausea or vomiting; the pathophysiology includes peripheral inhibitory effects of opioids on gastrointestinal transit or stimulation of the pyloric sphincter, delaying gastric emptying or causing gastroparesis. However, the primary mechanism of opioid-induced nausea and vomiting is central, with direct stimulation of the chemoreceptor trigger zone in the area postrema in the floor of the fourth ventricle. The clinical efficacy of 5-HT3 antagonists in opioid-induced emesis supports the hypothesis that stimulation of the area postrema may also be relevant to morphine-induced emesis in humans. The addition of a prokinetic (e.g., metoclopramide), prochlorperazine, or a 5-HT3 antagonist (-setron) to the opiate regimen is beneficial. ref: Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol. 2017;15(9):1338-1349. doi:10.1016/j.cgh.2017.05.014
Roumin (prochlorperazine maleate) has been prescribed properly. There is no medication reconciliation issue with the active prescription.
[diagnosis] - 2023-04-14 admission note
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[SOAP]
[radiotherapy]
[chemotherapy]
[assessment]
[assessment]
[diagnosis] - 2023-04-07 admission note
[exam findings]
[SOAP]
[surgical operation]
[note]
Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) for advanced pancreatic and biliary cancer 2023-04-14 https://www.uptodate.com/contents/image?imageKey=ONC%2F89668
Treatment protocols for pancreatic cancer REGIMENS 2023-04-14 https://www.uptodate.com/contents/treatment-protocols-for-pancreatic-cancer
[assessment]
Brosym (cefoperazone + sulbactam) 4g IVD Q12H has been prescribed fot the patient’s BTI.
It is considered to use nab-paclitaxel plus gemcitabine to treat the patient after her BTI is controlled. Please ensure that the ANC is >1500/uL and the platelet count is >100K/uL prior to administering the regimen. Sepsis has occurred in patients with or without neutropenia (risk factors are biliary obstruction or presence of a biliary stent). During the treatment, it is recommended to initiate broad-spectrum antibiotics in the presence of fever, even if not neutropenic. Interrupt nabpaclitaxel and gemcitabine until sepsis resolves and, if neutropenic, until neutrophils are at least 1500/uL, then resume at lower doses.
No medication reconciliation issues were noted for the patient.
{not completed}
[past history]
[allergy]
[family history]
[exam findings]
[SOAP]
[assessment]
[diagnosis] - 2023-03-24 admission note
[past history]
Dx history: - Gout - IDA - Alzheimer’s disease - CAD - CVA
Surgery history: - C-spine compression fracture s/p over 10 years ago
[allergy]
[family history]
Father: Liver cancer
[lab data]
[exam findings]
[consultation]
[surigcal operation]
[chemotherapy]
The patient has received a reduced dose of 65mg/m2 of oxaliplatin for the first time during this hospitalization, and no adverse reactions have been observed to date.
For the patient’s chronic viral hepatitis B and post-pancreatico-duodenectomy status, Protase (pancrelipase 280mg) TIDCC and Baraclude (entecavir 0.5mg) QDAC have been prescribed.
There is no medication reconciliation issue found.
[exam findings]
[SOAP]
[chemoimmunotherapy]
[exam findings]
[POMR]
[SOAP]
[chemotherapy]
Induction therapy for acute myeloid leukemia in medically-fit adults. 2023-04-10 https://www.uptodate.com/contents/induction-therapy-for-acute-myeloid-leukemia-in-medically-fit-adults
[follow up]
Bicytopenia progresses, Cravit (levofloxacin) and FLU-D (fluconazole) are used to manage potential infections.
No fever in the past 7 days.
Blast decreased after 7+3 anthracycline plus cytarabine since 2023-03-31.
The patient diagnosed with AML was admitted and received the first dose of “3+7 daunorubicin/cytarabine” regimen on 2023-03-31. Lab data showed the development of severe neutropenia following administration of the regimen.
Treatment with the regimen can cause 3 to 5 weeks of profound cytopenias and associated risks of life-threatening infections and bleeding. And cytarabine may cause a flu-like syndrome (including fever and/or rash) and daunorubicin can be associated with infusion reactions and cardiac arrhythmias.
It is recommended that a bone marrow examination be performed 14 to 21 days after initiation of therapy to assess the initial response to the therapy and to determine if a second induction course is needed.
Initial response to therapy - A bone marrow examination on day 14 of treatment provides an assessment of the clearance of blast cells and a preview of the response to induction therapy. Findings from the day 14 examination may be classified as follows:
Institutions vary in their responses to findings of the day 14 bone marrow examination.
Cravit (levofloxacin) and Flu-D (fluconazole) both have been prescribed to prevent or alleviate the patient from infections. There is no problem that is identified with the active recipe.
{not completed}
[exam findings]
[consultation]
{not completed}
[exam findings]
[consultation]
[lab data]
2023-04-11 Ferritin 1154.7 ng/mL
2023-04-11 Transferrin 143.6 mg/dL
2023-04-11 Fe (Iron-bound) 123 ug/dL
2023-04-11 TIBC 206 ug/dL
2023-04-11 UIBC 83 ug/dL
2023-04-10 BUN 29 mg/dL
2023-04-10 Bilirubin direct 0.22 mg/dL
2023-03-21 Direct Coomb Test Positive
2023-03-21 Indirect Coomb Test Positive
2023-03-21 FKLC 156.0 mg/L
2023-03-21 FLLC 193.0 mg/L
2023-03-17 Anti-beta2-glycoprotein-I Ab 9.2 U/mL
2023-03-17 Gamma 44.3 %
2023-03-15 IgG (blood) 2208 mg/dL
2023-03-09 stool FOB Positive
2023-03-09 Transferrin, stool Postive
[diagnosis] - 2023-04-10 admission note
[past history]
[allergy]
[family history]
[exam findings]
[SOAP]
[chemotherapy]
| he tumor marker CEA was found to be elevated and increasing before the first chemotherapy, and further follow-up tests can be ordered as necessary. |
|---|
| 023-03-08 CEA: 217.89 ng/mL |
The treatment strategy planned on 2023-03-21 is based on the results of PET: if it indicates the presence of metastases, the recommended chemotherapy regimen for concurrent chemoradiotherapy (CCRT) and post-CCRT would be FOLFOX, and total neoadjuvant therapy (TNT) would not be necessary. However, if PET shows that the lesion in the liver is not a metastasis, then the recommended treatment would be TNT, which consists of CCRT with FU, followed by FOLFOX for 6-8 cycles, then surgery and postoperative follow-up. The chemotherapy regimen for CCRT in this case would be FU.
On 2023-03-10, the results of the PET scan were available and the patient began receiving the FOLFOX regimen for the first time while in this hospital stay.
According to the patient’s blood glucose records, there is an upward trend and significant variability in his blood glucose levels despite taking Forxiga (dapagliflozin). To address this, it is recommended to investigate if there has been a significant change in the patient’s dietary intake, especially in regards to carbohydrate consumption, as this could have a substantial impact on blood glucose levels.
[exam findings]
[consultation]
[medication]
[note]
Capecitabine 2023-04-11 https://www.uptodate.com/contents/capecitabine-drug-information
[assessment]
The supplemental report for the IHC staining of EGFR, PMS2, MSH6, MSH2, and MLH1 for the colon biopsy pathology performed on 2023-03-10 is still pending and not yet available.
The patient’s last recorded height on 2023-03-30 is 172 cm, and his last recorded weight on 2023-04-10 is 75.7 kg. Based on these measurements, his body surface area (BSA) is calculated to be 1.9 m2. The patient has been receiving capecitabine at a daily dose of 2000 mg since late March 2023, which is a dose of 1052 mg/m2 based on his BSA. This is approximately 84% of the recommended daily dose of 1250 mg/m2.
It appears that the patient has had anemia even before the administration of capecitabine, and the cause may be gastrointestinal bleeding (in case of A-colon lesions?) as evidenced by positive occult blood in the stool. Blood transfusion performed on 2023-03-07, 2023-03-29, and 2023-04-07 and PPI is currently prescribed.
There is currently no record of hand-and-foot syndrome (HFS) or any related symptoms such as palmar-plantar erythrodysesthesia or chemotherapy-induced acral erythema.
[diagnosis] - 2023-04-02 admission note
[past history] - 2023-04-02 admission note
[allergy]
[family history]
[exam findings]
[consultation]
[SOAP}
[surgical operation]
[radiotherapy]
[chemotherapy]
The patient’s sputum Gram’s stain results on 2023-04-02 showed G(+) Cocci 2+, GNB 2+, GPB 3+ (Neutrophil/LPF < 10, Epithelial cell/LPF 15~20). Antibiotics with Betamycin 4.5gm Q6H have been prescribed since the same day to treat the patient’s respiratory symptoms. After checking the PharmaCloud database, no medication reconciliation issue is found.
[ciclosporin TDM]
On 2023-04-08, the patient’s ciclosporin trough concentration was found to be 169ng/mL, which falls within the acceptable range of 100 to 400ng/mL. However, if the target trough concentration is between 200 and 300 ng/mL, then it is recommended to increase the daily dose from the current 200mg to 250mg and continue with regular follow-up testing.
The patient’s kidney function results have returned to normal within the last 7 days.
2023-04-03 Creatinine 0.95 mg/dL
2023-03-31 Creatinine 2.45 mg/dL
2023-03-30 Creatinine 3.10 mg/dL
2023-03-28 Creatinine 3.74 mg/dL
2023-04-03 eGFR 98.94
2023-03-31 eGFR 33.16
2023-03-30 eGFR 25.27
2023-03-28 eGFR 20.35
[cyclosporine IV to PO conversion]
[ciclosporin TDM]
[therapeutic drug monitoring for cyclosporine]
[assessment]
[therapeutic drug monitoring for cyclosporine]
The dose of cyclosporine was increased from the original 140mg to 145mg on a later time on 2023-03-01, and further increased to 170mg on 2023-03-02, while the dosing frequency remained Q12H.
The TDM for cyclosporine was performed on 2023-03-02 at 08:26:39, and the administration time was recorded as 2023-03-02 11:46. The scheduled administration times for Q12H should be 09:00 and 21:00, and the later actual administration time may be due to delayed medication or delayed registration in the system, so it is recommended to confirm the system usage with nursing staff. However, the 08:26 blood draw is consistent with the trough concentration at Q12H.
Since the dose increase has not reached steady state, it is recommended to perform another blood draw in the middle of next week.
[cyclosporine TDM]
[therapeutic drug monitoring]
Sandimmun injection (ciclosporin)
The recommended therapeutic trough concentration range for cyclosporine typically falls within 100-400 ng/mL. The current administration is 140mg IVD Q12H.
Based on the TDM result on 2023-02-23 indicating a level of 43.3 ng/mL, it is suggested to administer a dosage of 180 mg per shot every 12 hours.
It is also recommended to perform another blood test to examine the trough concentration in the latter half of next week.
The echocardiography performed on 2023-01-06 showed an improved LVEF (55% versus 33%) compared to 2022-11-11.
Readings of bilirubin (direct/total) are within normal limits. AST/ALT levels indicate that impaired liver function is improving. There is no need to adjust the dose of medications in the active prescription for liver function. In addition, there is no laboratory evidence of impaired kidney function.
In spite of the fact that Hydrea (hydroxyurea) has been administered since 2023-01-27 afternoon, there has not been an obvious decrease in WBC counts since the second day of administration. The blast percentage remains around 60% with only minor fluctuations.
The PLT count has been trending downward, which should be closely monitored.
The active prescription does not pose a problem.
[drug identification]
We have been requested by the patient’s primary nurse to identify one drug. The drug is identified as Vemlidy (tenofovir alafenamide 25 mg) and is indicated for the treatment of chronic hepatitis B virus (HBV) infection in adults and pediatric patients 12 years of age and older with compensated liver disease. The in-hospital porter will return the identified drug to the ward.
Not used:
[exam findings]
[consultation]
[SOAP]
[multiteam]
[diagnosis] - 2023-04-07 discharge note
[exam findings]
[SOAP]
[chemotherapy]
[note]
TPF regimen (in-hospital Chemotherapy Regimens for Head and Neck Cancer: Collection as of 2022-02-11)
Neoadjuvant Chemotherapy regimen
[assessment]
[exam findings]
[chemotherapy]
[assessment]
Most patients achieve cooling of the oral mucosa through intraoral administration of ice chips during chemotherapy administration. This is a cost effective and proven beneficial treatment.
Both topical and systemic analgesic approaches have been used to manage pain associated with mucositis.
Currently, lidocaine 2% PO PRNQD and tramadol IVD PRNQ6H have been prescribed.
The diet should be limited to foods that do not require significant chewing; acidic, salty, or dry foods should be avoided.
If poor feeding compromises the patient’s nutritional status, placement of a nasogastric feeding tube may be considered.
[diagnosis] - 2023-04-03 discharge note
[lab data]
2023-02-23 HBsAg Nonreactive
2023-02-23 HBsAg (Value) 0.35 S/CO
2023-02-23 Anti-HCV Nonreactive
2023-02-23 Anti-HCV Value 0.07 S/CO
2023-02-23 Anti-HBs 11.15 mIU/mL
2023-02-23 Anti-HBc Reactive
2023-02-23 Anti-HBc-Value 6.43 S/CO
2023-02-23 Anti-HBc IgM Nonreactive
2023-02-23 Anti-HBc IgM Value 0.10 S/CO
2023-02-10 ANA Negative
2023-02-10 LA1 39.3 sec
2023-02-10 LA2 30.7 sec
2023-02-10 LA1/LA2 ratio 1.2
2023-02-08 Anti-Cardiolopin IgG 0.7 GPL-U/mL
2023-02-08 Anti-cardiolipin-IgM <0.8 MPL U/mL
2023-02-08 Anti-β2-glycoprotein-I Ab 0.9 U/mL
2023-02-08 Anti-ENA Sm 1.2 EliA U/ml
2023-02-08 Anti-ENA RNP 1.1 EliA U/ml
[SOAP]
[immunotherapy]
[assessment]
The patient’s PharmaCloud is currently inaccessible. However, based on in-hospital records, the patient received prednisolone at a dose of 80mg daily from 2023-02-08 to 2023-02-22, and dexamethasone at a dose of 8mg daily from 2023-03-10 to 2023-04-07. The patient also received rituximab on 2023-02-23, 2023-03-17, and 2023-04-03.
The peak in PLT count on 2023-03-01 occurred approximately 1 week after the first dose of rituximab and was not during steroid administration. There has been no similar increase since the second dose of rituximab. It is possible that this peak was due to the delayed effect of rituximab, which can take some time for platelet production to increase after treatment. However, without further information, it is difficult to determine the exact cause. Close monitoring of the patient’s platelet levels and response to treatment is recommended.
Lab data from 2023-02-08 and 2023-02-10 showed normal values for ANA, LA1, LA2, LA1/LA2 ratio, anti-cardiolipin IgG, anti-cardiolipin IgM, anti-beta2-glycoprotein-I Ab, anti-ENA Sm, anti-ENA RNP, and PT, INR, APTT.
In the event that rituximab is no longer effective, splenectomy or TPO-RAs may be considered options.
{EGFR wild type Adenocarcinoma of RUL with liver metastases, T4N0M1c, stageIVB - not completed}
[diagnosis] - 2023-04-02 admission note
[past history]
[allergy]
[family history]
[exam findings]
EGFR wild type Adenocarcinoma of RUL with liver metastases,T4N0M1c,stageIVB
Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
Chest CT without IV contrast ehnancement shows: Chest: S/p port-A placement with its tip at Superior vena cava. Massive bilateral pleural effuison and loculated effusion at right hemithorax is found. Patent airway is found. There is no evidence of mediastinal LAP
Visible abdomen: Atrophy of both kidneys are found. The GB is well distended without soft tissue lesion The spleen, pancreas and adrenals are intact. Low density lesion at S4 and S2 of liver is found. Liver meta is considered. In comparison with CT dated on 2022-09-28, regression of the tumor is found. There is no evidence of paraarotic LAPs. There is no ascites accumulation at abdominal cavity. Suggest clinical correlation
Imp: Loculated effusion at both hemithorax. Liver tumor, in regression.
History:眩暈,想吐,表偶爾會流鼻水,有血絲 Nausea without vomit for 2-3 days, mild dizziness SOB sometimes, very mild Abd distension since last chemo(6 days ago) 20220705 CT：RUL lung ca & liver mets;T3N2M1c, cSTAGE:IVB
MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.
This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
Findings: 1. Prior CT identified liver metastases in both lobes are noted again, mild decreasing in size. Please correlate with contrast enhanced dynamic CT or MRI. 2. There are bilateral extensive destructive centrilobular emphysema with upper lobes predominant. Prior CT identified RUL lung periphereal mass measuring 5.2 cm is noted again, decreasing in size. Please correlate with contrast enhanced CT. 3. Prior CT identified few cysts in S1 and S2 are noted again, stationary. 4. There are several renal stones, bilateral. Both kidney show small size and thin parenchyma that are c/w chronic renal disease. 5. There is no hyper-or hypodense lesion in the gallbladder, biliary system, pancreas, and spleen. There is no ascites or lymphadenopathy. There is no bowel wall thickening, and no bowel obstruction. The abdominal aorta and IVC are grossly unremarkable. There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
IMP: 1. Prior CT identified liver metastases in both lobes are noted again, mild decreasing in size. Please correlate with contrast enhanced dynamic CT or MRI. 2. Prior CT identified RUL lung periphereal mass measuring 5.2 cm is noted again, decreasing in size. Please correlate with contrast enhanced CT.
[SOAP]
[chemotherapy] (not completed)
2023-01-05 - docetaxel 35mg/m2 54mg D5W 150mL 1hr (WBC 1.3K/uL 2023-01-12, WBC 2.15K/uL 2023-01-14)
2022-12-15 - ditto (WBC 1.87K/uL 2022-12-22, WBC 1.42K/uL 2022-12-26)
2022-12-01 - ditto (WBC 2.54K/uL 2022-12-13)
2022-11-15 - ditto (WBC 2.67K/uL 2022-11-29)
2022-11-03 - ditto
2022-10-25 - ditto
2022-10-18 - ditto
2022-10-06 - ditto
2022-09-22 - ditto
2022-09-15 - ditto
2022-09-01 - ditto
2022-08-25 - ditto
2022-08-10 - ditto
2022-07-19 - pemetrexed 500mg/m2 818mg NS 100mL 10min + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 120mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin)
[medication]
[assessment]
[diagnosis] - 2023-04-02 admission note
[past history]
[allergy]
[family history]
[lab data]
2023-04-03 HBsAg Nonreactive
2023-04-03 HBsAg (Value) 0.52 S/CO
2023-04-03 Anti-HBc Nonreactive
2023-04-03 Anti-HBc-Value 0.91 S/CO
2023-04-03 Anti-HCV Nonreactive
2023-04-03 Anti-HCV Value 0.05 S/CO
2023-04-03 Anti HTLV I/II Nonreactive
2023-04-03 Anti HTLV I/II Value 0.05 S/CO
2023-04-03 HIV Ab-EIA Nonreactive
2023-04-03 Anti-HIV Value 0.06 S/CO
2023-04-03 CMV_IgG Reactive
2023-04-03 CMV_IgG Value 213.4 AU/mL
2023-04-03 CMV IgM Nonreactive
2023-04-03 CMV IgM Value 0.23 Index
[exam findings]
[consultation]
[radiotherapy]
[chemoimmunotherapy] (not completed)
[note]
Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in medically-fit patients (ref: https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients)
[diagnosis] - 2023-04-01 admisstion note
[present illness] - 2023-04-01 admisstion note
[exam findings]
[SOAP]
[assessment]
The patient’s fever appears to have improved (with a temperature not exceeding 37.5 degrees Celsius) since the administration of Flumarin (flomoxef) on 2023-04-01. However, blood and urine cultures are not yet available.
The patient has a high bilirubin level and is icteric 2+. The elevation of serum alkaline phosphatase, which is out of proportion to the serum aminotransferases, indicates possible biliary obstruction or intrahepatic cholestasis. An increased serum alkaline phosphatase is also observed in granulomatous liver diseases, such as tuberculosis or sarcoidosis.
Based on the CT performed on 2023-04-01, there is evidence of liver, lung, lymph node metastasis, and peritoneal carcinomatosis. Further evaluation is recommended, such as ultrasound, magnetic resonance cholangiopancreatography (MRCP), or endoscopic retrograde cholangiopancreatography (ERCP) to investigate the presence of intra- or extrahepatic bile duct dilation.
The patient was prescribed Vemlidy (tenofovir alafenamide) appropriately following a positive anti-HBc test result on 2023-03-14.
According to PharmaCloud records, medications were prescribed for pulmonary symptoms at Cardinal Tien Hospital in January 2023. If these symptoms are no longer present, then there are no medication reconciliation issues.
[diagnosis] - 2023-03-30 admission note
[exam findings]
[assessment]
[diagnosis] - 2023-03-10 discharge note
[exam findings]
[consultation]
[SDM] - 2023-02-02
[surgical operation]
[chemotherapy]
Induction chemotherapy should be used when chemotherapy occurs before radiation therapy. The term neoadjuvant chemotherapy should be used to refer to chemotherapy before surgery. ref: https://www.healthline.com/health/cancer/induction-chemotherapy
[assessment]
The patient has received (planned total 9-dose) TPF neoadjuvant regimen on 6 occasions, specifically on 2023-02-03, 2023-02-13, 2023-02-27, 2023-03-06, 2023-03-22, and 2023-03-31 (the 6th time during this hospitalization). There was only one episode of WBC less than 3K/uL, which occurred on 2023-02-10, approximately 1 week after the first dose. Otherwise, no other episodes of low WBC count were observed.
The TPF regimen was appropriately dose reduced from the second dose, with docetaxel at 32mg/m2 instead of 40mg/m2, cisplatin at 32mg/m2 instead of 40mg/m2, and fluorouracil at 900-800mg/m2 instead of 1000mg/m2. G-CSF was also used in a timely manner.
According to the latest information, there are no moderate or severe complaints for the patient about adverse reactions.
By the way, there is a decreasing trend in HGB, which indicates that the HGB does not seem to be fully recovered at the current administration interval/frequency. Please continue monitoring and check for need for blood transfusion for the next 3 scheduled doses.
[diagnosis] - 2023-03-09 admission note
[lab data]
[exam findings]
[consultation]
[SOAP]
[chemotherapy]
2023-03-30 CRP 18.82mg/dL, WBC 12.95K/uL, urine bacteria 1+, urine protein 1+. Blood culture results are not yet available.
There have been no medication reconciliation issues found in the patient. (PharmaCloud not accessible)
[present illness] - 2023-03-29 admission note
This is 77-year-old man who has past medical history of Raynaud phenomenon, Diabetes Type II, right lung adenocarcioma RLL status post VATS wedge resection, prostatic cancer status post TURP under regular oral endoxan and prednisolone. This time, he complained of dyspnea for days, OPD CXR showed right pleural effusion. Loss 5 kg due to poor appetite in one month according to himself. He was admitted to our ward for further evalation and treatment.
[past history]
[allergy]
[family history]
[SOAP]
[medication]
[assessment]
[diagnosis] - 2023-03-06 admission note
[past history]
Heart:(-)
Liver:(-)
Kidney:(-)
H/T:(-)
DM:(-) Other
DVT 2 years ago
medication: Rivaroxaban regularly and had taken Leuplin
Surgical: denied
Menstrual history: G0P0, Last menstrual period: 2022-09-25
sex –
Menarche at the age of 12 years old
Menstrual cycle:irregular with duration of 7 days
Amount: moderate with blood clots
Pap smear: denied
[allergy]
[family history]
[exam findings]
[surgical operation]
[radiotherapy]
[chemotherapy]
On 2023-03-29, the patient’s lab results indicated generally normal blood cell counts, selected electrolytes, and liver/kidney functions. There is no evidence that contraindicates the scheduled chemotherapy. The patient was diagnosed with acute embolism and thrombosis of the femoral and iliac veins on 2020-11-16 and has been taking Xarelto (rivaroxaban) for this condition. After reviewing the PharmaCloud database, no medication reconciliation issues were identified.
After a leukopenia event (WBC 1.65K/uL on 2022-12-31), all subsequent data showed WBC counts above 5K/uL. Since receiving paclitaxel + carboplatin regimen in late November 2022, there have been no observations of anemia and/or thrombocytopenia. The patient is currently taking rivaroxaban as a self-carried medication due to a history of DVT. No medication reconciliation issues were found during this hospital stay.
Based on the lab results (2022-12-19), the scheduled chemotherapy did not appear to be contraindicated.
[diagnosis] - 2023-03-03 admission note
[past history]
[allergy]
[family history]
[exam findings]
Right liver cysts (3.57x4.19cm, 1.26x1.32cm).
Gallbladder stones (3-5mm).
2023-01-06 SONO - thyroid gland.
2023-01-06, 2022-12-02, -10-28 Nasopharyngoscopy
2022-11-24 Gynecologic ultrasonography
2022-11-16 CT - abdomen
2022-09-08 MRI - nasopharynx
2022-09-01, -06-02 SONO - abdomen
2022-06-14 ECG
2022-06-14 CXR
2022-06-14 PTA
2022-04-28 Tc-99m MDP whole body bone scan
2022-04-28 Gynecologic ultrasonography
2022-04-27 Panendoscopy
2022-04-27 SONO - abdomen
2022-04-26 MRI - nasopharynx
2022-04-26 PTA
2022-04-25 ECG
2022-04-18 PTA
2022-04-11 Patho - nasopharyngeal/oropharyngeal biopsy
2022-04-11 Otologic endoscopy
2022-04-11 Nasopharyngoscopy
2022-03-12 SONO - abdomen
2020-12-16 2D transthoracic echocardiography
[SOAP]
[radiotherapy]
[chemoimmunotherapy]
The patient was prescribed ergometrine maleate for an unspecified leiomyoma of uterus by our gynecologist on 2023-03-03. However, this drug is not currently shown in the active medication list. It has no known interaction with the patient’s current medications. Therefore, adding it as a self-carried item to the active medication list is recommended for proper medication reconciliation.
In addition, it is noted that fluorouracil, metoclopramide, and hydroxychloroquine are potential QT-prolonging agents. Administration of these drugs in an overlapping manner may enhance the QTc-prolonging effect, which should be monitored.
[exam findings]
[SOAP]
[radiotherapy]
[chemotherapy]
[assessment]
The patient was diagnosed with low rectal cancer involving the anal canal with bleeding, cT4bN1bM0, stage: IIIC.
For patients with locally advanced rectal cancer who are at high risk for a margin-positive resection or node-positive disease with a low-lying rectal tumor, total neoadjuvant therapy (TNT) is suggested instead of long-course CRT or short-course RT alone. TNT combines oxaliplatin-based chemotherapy with long-course CRT or short-course RT, leading to increased chemotherapy compliance, improved local control, and the ability to consider nonoperative treatment if the patient declines surgery.
The patient has been admitted to receive her first dose of FOLFOX. Lab results on 2023-03-23 showed normal liver and kidney function, blood cell counts, serum electrolytes, and no contraindications to chemotherapy.
The patient’s chronic viral hepatitis B without the delta agent is currently being managed with Baraclude (entecavir).
The current active prescription has no identified issues.
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
[assessment]
The patient experienced nadir levels in her WBC and/or PLT count approximately one week after receiving chemotherapy, as indicated by asterisks in the table below (WBC < 3K/uL, PLT < 100K/uL).
The patient was admitted for her scheduled chemotherapy with a 20% dose reduction of paclitaxel due to her not fully recovered low PLT level.
No medication reconciliation issues were found after reviewing PharmaCloud and comparing it to the active prescription.
[exam findings]
[assessment]
[past history] - 2023-03-25 admission note
[allergy]
[family history]
[exam findings]
[consultation]
[SOAP]
[chemotherapy]
[medication]
[assessment]
[diagnosis] - 2023-03-27 admission note
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
The patient underwent surgery for feeding jejunostomy and port-A placement on 2023-02-20 and she began receiving cisplatin and fluorouracil starting from 2023-02-27.
Patients who have undergone feeding jejunostomy surgery often require additional nutritional support and close monitoring of their hydration status. All the oral drugs in the current prescription are compatible with tube feeding.
[diagnosis] - 2023-03-27 admission note
[past history]
[allergy]
[family history]
[exam findings]
[surigcal operation]
[chemoimmunotherapy]
2023-03-27 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOXIRI)
2023-03-01 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOXIRI)
2023-02-07 (Avastin + FOLFOX)
2023-01-09 (Avastin + FOLFOX)
2022-12-12 (Avastin + FOLFOX)
2022-11-18 (Avastin + FOLFOX)
2022-10-26 (Avastin + FOLFOX)
2022-07-04 (Avastin + FOLFIRI)
2022-06-08 (Avastin + FOLFIRI)
2022-05-16 (Avastin + FOLFIRI)
2022-04-20 (Avastin + FOLFIRI)
2022-03-29 (Avastin + FOLFIRI)
2022-03-04 (Avastin + FOLFIRI)
2022-02-11 (Avastin + FOLFIRI)
2022-01-12 (Avastin + FOLFIRI)
2021-12-27 (Avastin + FOLFIRI)
[assessment]
[diagnosis] - 2023-03-28 discharge note
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
{Chronic myelomonocytic leukemia, CMMoL}
[ciclosporin TDM]
Based on the available system records, the blood for ciclosporin was drawn at 00:48 on 2023-03-27, approximately 4 hours after medication administration at 20:32 on 2023-03-26. If the purpose of the blood draw was to measure the trough concentration, the ideal time to draw blood is within 30 minutes before next scheduled medication administration. Therefore, it is recommended to verify the accuracy of the system records or to redraw a blood sample at the appropriate time for accurate measurement.
The recorded concentration result for ciclosporin is 331.4ng/mL, but its accuracy as a trough level may be questionable due to the possibility of an inappropriate blood draw time.
The peak concentration of cyclosporine-A was 326 ng/mL on 2022-12-12, which is within the normal therapeutic range.
2022-12-13 WBC 670/uL, PLT 2000/uL.
[cyclosporine trough concentration]
As a follow-up of the change in dose of cyclosporine from 100mg Q12H to 120mg Q12H since 2022-11-25, it is recommended that the trough concentration of cyclosporine be renewed by drawing blood within 30 minutes of the first dose on 2022-11-29.
[cyclosporine trough concentration]
Following the administration of 100 mg Q12H since 2022-11-21, a blood sample was taken for cyclosporine trough concentration, and the level was 63.9 ng/mL. In general, the effective range is considered to be between 100 and 400 ng/mL. In the event that the clinical effect not shown, increasing the daily dose to 300mg (divided in 3 seperate administration) can be considered and then recheck the trough concentration 3 days after the dose alteration. The goal is to limit the concentration with a minimum dose while retaining the necessary clinical effect.
According to UpToDate database, cyclosporine for patients with altered kidney function, CrCl <60 mL/minute: No dosage adjustment necessary (0.1% excreted in the urine unchanged) (Nemecek 2019; expert opinion). For nontransplant indications (eg, autoimmune disease), the manufacturer’s labeling states use is contraindicated in patients with abnormal renal function (not defined); however, when potential benefits outweigh the risks, may consider cautious use with frequent monitoring of kidney function, or consider use of an alternative agent due to increased risk of worsening kidney function, especially for patients with more severe impairment (expert opinion).
2022-10-20 eGFR 35. The dosage of prescribed drugs is within the recommended range for patients with altered kidney function.
[Diagnosis] - 2023-03-27 admission note
[present illness] - 2023-03-27 admission note
[past history] - 2023-03-27 admission note
[allergy]
[family history]
[exam findings]
[surgical operation]
[chemotherapy]
[assessment]
[diagnosis] - 2023-03-13 admission note
[past history]
[allergy]
[family history]
[exam findings]
MRI (111-2-5, NTUH): 1. operative change of the left lobe of liver; no evidence of local residual tumor is noted; 2. focal area 39.5mm in the surgical margins is noted; the lesion was not identified on MR 2020/9/8; new recurrent tumor is considered. (arrow key images) 3. hepatic veins and portal veins are patent 4. there are no focal lesions in the spleen pancreas both adrenal and kidneys; a tiny cyst in the left kidney; 5. there is no evidence of paraaortic LAPs in abdomen; there is no evidence of paraaortic LAPs in pelvic cavity and bilateral inguingal areas. 6. there is no ascites 7. enlarged prostate is noted with posterior urinary bladder indentation; 8. hydrocele of the left scrotum. PET (111-3-2, NTUH): Some intense hot areas along medial border of the liver (figures 1-1 to 1-4, SUVmax=11.85). * Some moderate hot spots at abdominal paraaortic nodes and left iliac nodes (figures 1-5 to 1-9, SUVmax=5.79). * A faint hot spot at right iliac crest (figure 1-10, SUVmax=1.34), probably benign. * Some mild hot areas at L1-L2 vertebral junction, right hip joint, and right ischial enthesis, probably arthritis and enthesitis. * Intense curvilinear-shaped hot areas at bowel loops, suspicious Metformin-related activity. Pathology (P2202854, 2022-3-26, NTUH): Liver segment 5 8 anatomical hepatectomy cholangiocarcinoma Gallbladder cholecystectomy chronic cholecystitis Lymph node peri-gallbladder lymphadenectomy minimal histological change (1/1). Histologic Grade Grade 2: Moderately differentiated (50% to 95% of tumor composed of glands). Margins (check all that apply) Hepatic Parenchymal Margin Uninvolved by invasive carcinoma. Lymph-Vascular Invasion: not identified. Perineural Invasion Not identified. Pathologic Staging (pTNM according to AJCC v.8): Primary Tumor (pT) pT1b: Solitary tumor ＞5cm without vascular invasion Regional Lymph Nodes (pN) pN0: No regional lymph node metastasis. MRI (111-5-4, NTUH): 1. operative change of the left lobe of liver; no evidence of local residual tumor is noted; 2. operative change of the anterior right lobe of liver; no evidence of local residual tumor is noted; a small biloma. 3. a recurrent tumor 34.5mm is noted at the S1 of the liver; cholangiocarcinoma is considered. 4. hepatic veins and portal veins are patent 5. there are no focal lesions in the spleen pancreas both adrenal and kidneys 6. there is no evidence of paraaortic LAPs in abdomen 7. there is no ascites
[consultation]
[radiotherapy]
[chemotherapy]
[exam findings]
[consultation]
[chemotherapy]
[exam findings]
[consultation]
[cancer multidisciplinary team meeting conclusion] - meeting date: 20221111
[chemoimmunotherapy]
[mucositis]
As of now, Comfflam Anti-inflammatory Spray (benzydamine 1.5 mg/mL) is available in this hospital and can be used as a rinse three to four times daily (depending on the severity of the mucositis).
{not completed}
[diagnosis] - 2023-03-22 admission note
[past history]
Irregular drug use
[allergy]
[family history]
[exam findings]
[consultation, not completed]
[radiotheray]
[chemotherapy]
[assessment]
[diagnosis] - 2023-03-22 admission note
[past history] - 20221213 admission note
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemoimmunotherapy]
[assessment 2023-01-14, not posted]
[assessment]
The patient had developed tinea unguium in Jan 2023, but there is no longer any evidence of the condition in the updated medical records.
The patient is currently admitted for his 10th cycle of Avastin + FOLFIRI chemoimmunotherapy, and it is planned that he will receive a total of 12 cycles. His liver and kidney function, as well as his electrolyte levels, are normal, although there is a slight anemia based on the 2023-03-21 lab results.
There were no medication reconciliation issues found in the patient.
CT results from 2023-01-31 indicate the presence of focal peritoneal infiltrates, which could suggest post-operative changes or disease recurrence. Further diagnostic tests or imaging studies may be necessary to make a definitive diagnosis and determine whether new treatment should be planned.
{not completed}
[exam findings]
[consultation]
[multiteam]
[surgical operation]
[radiotherapy]
[chemotherapy]
PharmaCloud database reports that Natrilix (indapamide) has been prescribed at VGHTPE on 2022-12-29 as a 84-day refillable prescription, along with other medications such as Norvasc (amlodipine), Betaloc (metoprolol), and Olmetec (olmesartan) to manage the patient’s hypertension. And this patient developed hyponatremia since 2023-02.
Indapamide is a type of diuretic known as a low-ceiling diuretic, which functions by inhibiting the sodium-chloride co-transporter in the kidneys. This leads to an increase in the excretion of both sodium and water from the body.
Treatment of diuretic-induced hyponatremia consists of discontinuing the diuretic and administering either isotonic saline or, if the hyponatremia is severe or symptomatic, hypertonic saline. There is a potential risk of overly rapid correction of the hyponatremia with either regimen. Once the diuretic has been cleared and the patient becomes euvolemic, antidiuretic hormone (ADH) release will be appropriately suppressed, resulting in the excretion of a dilute urine, which can lead to rapid excretion of the excess water. Thus, patients with moderate to severe hyponatremia must be monitored carefully during treatment to minimize the risk of osmotic demyelination.
It is recommended to monitor serum Na levels at a frequency no less than every 12 hours, ensuring that any changes in serum Na levels do not exceed 4-6mEq/L within a 24-hour period to avoid the development of osmotic demyelination syndrome (ODS). Additionally, it is advised to monitor urine output and neurological symptoms. Other recommended tests include checking serum osmolality, TSH, free T4, ACTH (at 8 am), cortisol (at 8 am), urine osmolality, Na, and Cre.
[exam findings]
[consultation]
{colon cancer - mucinous adenocarcinoma}
[lab data]
2020-09-30 NRAS/KRAS detected
2020-09-30 KRAS 12/13 Not detected
2020-09-30 BRAF Not detected
2020-08-28 HBsAg (NM) Negative
2020-08-28 HBsAg Value (NM) 0.365
2020-08-28 Anti-HBs (NM) Negative
2020-08-28 Anti-HBs value (NM) <2.00
2020-08-28 Anti-HBc (NM) Negative
2020-08-28 Anti-HBc Value (NM) 2.15
2020-08-28 Anti-HCV (NM) Negative
2020-08-28 Anti-HCV Value (NM) 0.0382
2020-08-28 HBsAg (NM) Negative
2020-08-28 HBsAg Value (NM) 0.365
2020-08-28 Anti-HBs (NM) Negative
2020-08-28 Anti-HBs value (NM) <2.00
2020-08-28 Anti-HBc (NM) Negative
2020-08-28 Anti-HBc Value (NM) 2.15
2020-08-28 Anti-HCV (NM) Negative
2020-08-28 Anti-HCV Value (NM) 0.0382
[exam findings]
[consultation]
[surgical operation]
[chemoimmunotherapy]
[assessment]
[exam findings]
[consultation]
[assessment]
{Metastatic colon adenocarcinoma in liver S4-5-8 & S6, pTxN0M1a Stage IVA, post segmental hepatectomy on 2019-06-05}
[diagnosis] - 2023-03-20 admission note
[past history] - 2022-11-25 admission note
[family history]
[lab data]
[exam findings]
A metastasis 3.9 x 2 cm in S7 of the liver S/P C/T with stable disease.
2019-11-21 Whole body PET scan
2019-11-11 CT - abdomen
2019-08-14 Tc-99m MDP whole body bone scan
2019-08-03 MRI - liver, spleen
2019-06-06 Surgical pathology Level V
2019-06-08 CT - abdomen
2019-05-20 CT - abdomen
2018-11-16 CT
2018-07-07 CT
2018-06-28 Surgical pathology Level III
2018-04-26 Surgical pathology Level VI
[consultation]
[surgical operation]
[chemotherapy]
dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
2022-11-25 - cetuximab 250mg/m2 480mg 2hr + oxaliplatin 60mg/m2 115mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5450mg 46hr (FOLFOXIRI Zhang_ShouYi)
2022-11-08 - cetuximab 250mg/m2 490mg 2hr + oxaliplatin 60mg/m2 118mg 2hr + irinotecan 150mg/m2 295mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-10-20 - cetuximab 250mg/m2 485mg 2hr + oxaliplatin 60mg/m2 116mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 775mg 2hr + 5-Fu 2800mg/m2 5430mg 46hr (Zhang_ShouYi)
2022-08-12 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 180mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)
2022-09-12 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)
2022-08-26 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5520mg 46hr (Zhang_ShouYi) patient asked to add oxaliplatin back.
2022-08-12 - cetuximab 250mg/m2 500mg 2hr + irinotecan 180mg/m2 350mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-07-21 - cetuximab 250mg/m2 500mg 2hr + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)
2022-07-01 - cetuximab 250mg/m2 500mg 2hr + irinotecan 160mg/m2 320mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)
2022-06-14 - cetuximab 250mg/m2 500mg 2hr + irinotecan 160mg/m2 320mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi) FOLFIRI
2022-05-24 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 185mg/m2 370mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)
2022-04-27 - cetuximab 400mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-03-29 - cetuximab 400mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-03-15 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-02-10 - cetuximab 400mg/m2 700mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-01-14 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 170mg/m2 330mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2021-12-22 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 160mg/m2 300mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)
2021-12-01 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)
2021-11-11 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5345mg 46hr (Zhang_ShouYi) FOLFOXIRI
2021-09-28 ~ 2021-11-09 - Stivarga (regorafenib 40mg/tab) 4# QD D1-21 Q4W
2021-09-03 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)
2021-08-20 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5640mg 46hr (Zhang_ShouYi)
2021-07-29 - oxaliplatin 70mg/m2 140mg 2hr + leucovorin 400mg/m2 805mg 2hr + 5-Fu 2800mg/m2 5660mg 46hr (Zhang_ShouYi)
2020-08-24 - bevacizumab 5mg/kg 200mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)
2020-07-27 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)
2020-06-29 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5460mg 46hr (Zhang_ShouYi)
2020-06-15 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)
2020-05-28 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 160mg/m2 300mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)
2020-05-07 - bevacizumab 300mg 90min + irinotecan 120mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + 5-Fu 400mg/m2 650mg 15min + 5-Fu 1000mg/m2 1500mg 20hr D1-2 (Liu_JunHuang)
2020-04-20 - bevacizumab 300mg 90min + irinotecan 120mg/m2 220mg 90min + leucovorin 400mg/m2 560mg 2hr + 5-Fu 400mg/m2 560mg 15min + 5-Fu 1000mg/m2 1500mg 20hr D1 (Liu_JunHuang)
2020-04-02 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1 (Liu_JunHuang)
2020-03-16 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)
2020-03-02 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)
2020-02-17 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)
2020-02-03 - irinotecan 270mg 1.5hr + leucovorin 400mg/m2 760mg 0hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)
2020-01-13 - oxaliplatin 85mg/m2 2hr + leucovorin 200mg/m2 380mg 0hr + 5-Fu 400mg/m2 684mg 15min D1-2 + 5-FU 1000 mg 20hr D1-2 (Liu_JunHuang)
2019-12-06 ~ 2019-12-28 - capecitabine
2019-06-12 - FOLFIRI + bevacizumab
2019-05-28 - FOLFIRI + bevacizumab
2019-05-07 - FOLFIRI + bevacizumab
2019-04-20 - FOLFIRI + bevacizumab
2019-04-03 - FOLFIRI + bevacizumab
2019-03-16 - FOLFIRI + bevacizumab
2019-03-02 - FOLFIRI + bevacizumab
2019-02-17 - FOLFIRI + bevacizumab
2019-02-03 - FOLFIRI
2019-01-03 - FOLFIRI
2018-06-08 ~ 2018-06-18: capecitabine
The control of blood sugar is better than it was during the last hospital stay. As far as the active prescription is concerned, there is no problem.
The patient continues to have poor blood sugar control despite treatment with acarbose, metformin, and vildagliptin (2 data points over 244 mg/dL on 2022-11-08 and 2022-11-09). SGLT2 inhibitors such as Canaglu (canagliflozin), Forxiga (dapagliflozin) or Jardiance (empagliflozin) might be added to help manage diabetes.
Although the patient is currently receiving 3 classes of oral antidiabetic medications (metformin, sitagliptin, and dapagliflozin), his blood sugar remains high (381mg/dL on 2022-09-12 17:35, 302mg/dL on 2022-09-13 06:46); HbA1c of 8.4 (2022-08-26 lab), mild diabetic retinopathy has been confirmed (2022-03-15 ophthalmology).
Starting basal insulin (e.g., Toujeo (insulin glargine)) at 0.1 unit/kg/day or 10 units/day is recommended.
Irinotecan 180 mg/m2 in current regimen is considered a normal dose range for patients with ALT/AST 43/44, BUN 10 (2022-07-21).
There is a history of T2DM in this patient. The most recent HbA1c record dates from 2019, and the AC blood sugar readings have been 271, 327, and 267 since this hospitalization. As there is no hypoglycemic agent in active prescriptions, metformin 500 mg BID is recommended.
CT and MRI in mid January 2022 showed the disease progressed compared to previous images.
CEA readings since July 2021 at intervals of two to three months showed a peak in November 2021 (1261ng/mL) and a slight fall in February 2022 (886ng/mL), possibly caused by the introduction of FOLFOXIRI from November 2021 (ongoing).
[diagnosis]
[past history]
[allergy]
[family history]
[exam findings]
[surgical operation]
[chemotherapy]
[note]
First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tube, and peritoneal cancer https://www.uptodate.com/contents/first-line-chemotherapy-for-advanced-stage-iii-or-iv-epithelial-ovarian-fallopian-tube-and-peritoneal-cancer
{not completed}
He was admitted for hemoptysis with blood clot from oral and nasal cavity for more than a week. History of NPC and CT imaging revealed possible tumor recurrence in Jan 2022.
[exam findings]
[consultation]
2023-03-17 Ear Nose Throat
2023-03-17 Infectious Disease
surgical operation
[drug identification]
The medication you are requesting drug identification for is Eltroxin, which contains levothyroxine at a dose of 0.05mg.
This medication is used to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone.
The medication will be sent back to the ward by an in-hospital porter.
[diagnosis] - 2023-03-17 admission note
[exam findings]
[consultation]
[surgical operation]
[C/T history]
C1D1 (#1) HD-MTX (8000mg/m2) on 2022/7/14, C1D2 Leucovorin (100 mg/m2) q6h until serum methotrexate <0.05 mmol/L and C1D3 Mabthera (375mg/m2) = 750mg on 2022/7/16. Rolican + HS hydration for AKI correct after HD-MTX. Feburic 80mg/tab (Febuxostat) 1# qod for prevent elevated uric acid.
C1D14 (#2) HD-MTX (due to AKI history, so change to 4000mg/m2) on 22022/8/09, Leucovorin 100mg q6h, Mabthera on 2022/8/11. Colchine and dexamethaxone for gouty arthritis treatment on 2022/8/17.
C2D1 (#3) HD-MTX (4g/m2), Covorin, Mabthera on 2022/8/24-8/26. C2D14(#4) HD-MTX (4g/m2), Covorin, Mabthera on 2022/9/12-9/14. C3D1 (#5) HD-MTX (4g/m2), Covorin, Mabthera on 2022/9/26-9/28.
2022/10/13 brain MRI: 1. Known a case of primary brain lymphoma. As compared with prior MRI (2022/06/20), marked shrinkage of left thalamus lesion (from 29mm to 12mm). But marked progression of lateral lesions (abutting left occipital horn) (from 15mm to 31mm). 2. Prominent peri-tumoral edema over left thalams and temporal lobe. C3D15 (#6) HD-MTX (8g/m2), Covorin, Mabthera on 2022/10/21-23.
He received the radiotherapy on 2022/11/2 -2022/12/6 with 3060cGy/17 fractions ofthe whole brain, and 4500cGy/25 fractions of the CNS lymphoma area.
C4D1 (#7) HD-MTX (8g/m2), Covorin,Mabthera on 2023/1/6-8. Followed up MRI of brain was performed on 2023/2/8 revealed No brain infarct was seen. Marked shrinkage of left thalamus and left occipital lesion. Marked regression of peri-tumoral edema.
This time, he was admitted for C4D15 (#8) chemotherapy HD MTX/Covorin/Mabthera on 2023/3/17.
[chemoimmunotherapy]
[dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg + NS 250mL] D2
2022-10-21 - methotrexate 8000mg/m2 16000mg 6hr D1 + rituximab 375mg/m2 745mg 8hr D3
2022-09-26 - methotrexate 4000mg/m2 7950mg 6hr D1 + rituximab 375mg/m2 745mg 8hr D3
2022-09-12 - methotrexate 4000mg/m2 7980mg 6hr D1 + rituximab 375mg/m2 748mg 8hr D3
2022-08-24 - methotrexate 4000mg/m2 7880mg 6hr D1 + rituximab 375mg/m2 740mg 8hr D3
2022-08-09 - methotrexate 4000mg/m2 7900mg 6hr D1 + rituximab 375mg/m2 744mg 8hr D3
2022-07-14 - methotrexate 8000mg/m2 16000mg 6hr D1 + rituximab 375mg/m2 750mg 8hr D3
[note]
methotrexate (https://www.uptodate.com/contents/methotrexate-drug-information 2022-07-20)
leucovorin (https://www.uptodate.com/contents/leucovorin-drug-information 2022-07-20)
Methotrexate induced acute renal failure is typically nonoliguric and is reversible in almost all cases. Plasma creatinine levels usually peak within the first week and return toward baseline levels within 1 to 3 weeks. The patient’s renal function is decreasing at a much slower rate over time, which is a positive sign that creatinine almost reaches its peak level.
The likelihood of MTX-induced renal dysfunction in patients receiving high dose MTX can be minimized (but not eliminated) by hydration both to maintain a high urine flow and to lower the concentration of MTX in the tubular fluid and by alkalinization of the urine to a pH above 7.0. Raising the urine pH from 5.0 to 7.0 increases the solubility of MTX 10-fold.
It is customary to begin the MTX infusion only after the urine pH is >= 7.0 and to maintain it in this range until plasma MTX levels have declined to less than 0.1 microM.
Urinary alkalinization is most easily accomplished by adding ampules of sodium bicarbonate to each liter of IV fluid hydration. This accomplishes both fluid hydration and urinary alkalinization. A typical choice is IV D5W with 100 to 150 mEq of sodium bicarbonate per liter, administered by continuous infusion at 125 to 150 mL/hour. A cation concentration of 80.5 mEq/L is roughly equivalent to one-half normal saline. The amount of bicarbonate in each liter and the IV fluid composition can then be modified according to the urine pH and serum sodium.
An alternative oral protocol for sodium bicarbonate can be started with 3000 mg (300mg/tab * 10 tablets) Q6H, and can be escalated the frequency to Q4H as needed; once the urine pH is greater than 7, the 24 hour daily dose can then be lowered and divided into four doses, every six hours.
Lab data indicated that the patient’s renal function is deterioating
In this male patient, who is 56 y/o, Cre 2.02 mg/dL and weighs 82 kg, the estimated CrCl is 47 mL/min. The self-carried Baraclude (entecavir) for patients with CrCl 30 to <50 mL/minute: Administer 50% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 48 hours. QODAC is preferred.
Methotrexate is greater 80% excreted as the unchanged drug and is primarily excreted in the urine. Leucovorin 100mg IVD Q6H has been administered since 2023-01-08 06:05.
Serum MTX levels are declining at an apparent rate.
If the patient is still able to urinate normally, furosemide may be an option for helping the excretion of methotrexate. For patients with an eGFR greater than 30 mL/minute/1.73m2, furosemide does not require dosage adjustment.
[lab data]
2023-03-17 Anti-HBc Nonreactive
2023-03-17 Anti-HBc-Value 0.18 S/CO
2023-03-17 Anti-HCV Nonreactive
2023-03-17 Anti-HCV Value 0.17 S/CO
2023-02-03 Anti-HCV Nonreactive
2023-02-03 Anti-HCV Value 0.10 S/CO
2023-02-03 HBsAg Nonreactive
2023-02-03 HBsAg (Value) 0.49 S/CO
2023-02-03 Anti-HBs 1.12 mIU/mL
2023-02-02 MTBC PCR NOT DETECTED
2023-02-02 MTBC PCR Value <11.8 CFU/ml
[exam findings]
[radiotherapy]
[chemotherapy]
[drug interaction]
Histamine H2 Receptor Antagonists may decrease the absorption of dasatinib. Dasatinib prescribing information states histamine H2 receptor antagonists (H2RAs) should not be coadministered with dasatinib due to the risk of reduced dasatinib concentrations and efficacy. Given the longer-term acid suppression achieved with H2-antagonist or proton pump inhibitor therapy, the manufacturer suggests the use of antacids (with 2-hour dose separation) if acid-reducing therapy is required. The likely mechanism for this apparent interaction is impaired absorption of dasatinib, which does appear to display pH-sensitive solubility, due to the increase in gastric pH caused by a H2-receptor antagonist.
Currently, the patient is prescribed Sprycel (dasatinib) and Ulstop (famotidine) with a QD and BID frequency, respectively. These medications are being administered at the same time of 09:00. To prevent any potential drug interactions, it is recommended to shift the administration time of one of the medications to a time that does not overlap with the other medication.
[exam findings]
[chemotherapy]
Granocyte (lenograstim 250ug/vial) CGRAN01 - 2023-03-02 ~ 2023-03-04 - 250ug QD SC - IPD 2023-03-02
[assessment]
{Malignant neoplasm of body of stomach; gastric antrum, pT4aN0M1, stage IV status post radical subtotal gastrectomy with lymph node dissection and B-II gastrojejunostomy}
[diagnosis] - 2023-02-04 discharge note
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemoimmunotherapy]
dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
2023-01-09 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 450mg 2hr + fluorouracil 2400mg/m2 2760mg 46hr
2022-12-22 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2400mg/m2 2840mg 46hr
2022-12-08 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 450mg 2hr + fluorouracil 2400mg/m2 2760mg 46hr
2022-11-17 - oxaliplatin 40mg/m2 47mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2000mg/m2 2360mg 46hr + [docetaxel 30mg/2 35mg IP 1hr + cisplatin 30mg/m2 35mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]
2022-10-25 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2000mg/m2 2370mg 46hr + [docetaxel 30mg/2 35mg IP 1hr + cisplatin 30mg/m2 35mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]
2022-09-13 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 490mg 2hr + fluorouracil 2000mg/m2 2470mg 46hr + [docetaxel 30mg/2 37mg IP 1hr + cisplatin 30mg/m2 37mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]
2022-08-30 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 490mg 2hr + fluorouracil 2000mg/m2 2470mg 46hr + [docetaxel 30mg/2 37mg IP 1hr + cisplatin 30mg/m2 37mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]
2022-08-08 - mitomycin-C 15mg/m2 20mg 2hr D2-3 + [fluorouracil 500mg/m2 645mg IP 1hr D1-5 + gentamicin 40mg IP 1hr D1-5 + sodium bicarbonate 2800mg IP 1hr D1-5]
According to available lab data since 2022-07-05 in HIS5, the patient has experienced frequent occurrences of hyponatremia, hypopotassemia, hypokalemia, and hypomagnesemia. However, during the same time frame, there have been few instances of hyper- or hypophosphatemia.
The patient began receiving FOLFOX treatment in August 2022, and the use of carboplatin in this treatment regimen can be associated with hyponatremia, hypokalemia, hypomagnesemia, and hypocalcemia.
It is recommended to continue monitoring the patient’s electrolyte levels and prescribe supplements as needed. If it becomes challenging to maintain a balance of electrolytes through supplementation, it may be necessary to consider reducing the dose of carboplatin or switching to a different regimen.
As multiple body fluid (primarily ascites) cytological studies (2022-11-18, -11-17, -10-27, -10-26, -10-04, -09-14, -09-13, -09-01, -08-30) did not reveal evidence of malignancy, intraperitoneal chemotherapy was discontinued while systemic FOLFOX is continued.
The lab serum magnesium levels indicated a frequent deficiency of serum magnesium in this patient.
For the magnesium sulfate prescription will expire on the weekend, a lab data renewal may assist in determining whether the magnesium supplement should continue to be administered.
Body weight has decreased by almost 10 kg in the last 3 months (33.1kg 2022-10-25 <- 42.8kg 2022-07-27 gastrectomized), and a low albumin level (3.2 g/dL 2022-10-25) could indicate malnutrition. Long-term survival may be adversely affected by malnutrition after gastrectomy for gastric cancer (ref: Impact of Malnutrition After Gastrectomy for Gastric Cancer on Long-Term Survival. Ann Surg Oncol. 2018;25(4):974-983. doi:10.1245/s10434-018-6342-8)
It is advisable to begin strict nutritional follow-up as soon as possible after surgery in order to prevent a sharp weight loss in the early postoperative phase when most of the dietary problems arise.
Vitamin B12 injections might be required, as well as multivitamins and minerals.
As this patient’s weight is approximately equivalent to that of a ten-year-old child, the dosage might need to be adjusted accordingly.
[diagnosis]
[past history]
[exam findings]
[consultation]
[radiotherapy]
s/p palliative RT on 2022/06/07 (RUQ tumor), 2022/07/18 (left hilum), 2022/08/05 (left hilum), 2022/10/21 (liver, SBRT), 2023/01/02 (LUL).
[immunotherapy]
Advanced uterine leiomyosarcoma (ULMS) remains an incurable disease in most cases, and despite new drug approvals, improvements in overall survival have been modest at best. Microsatellite instability and/or high tumor mutational burden are distinctly uncommon in uterine LMS, perhaps explaining the lack of activity of immunotherapy agents observed in phase II trials in LMS.
Based on the available lab data in HIS5 since 2020-09-09, the patient’s HGB level has never reached the lower limit of normal. In 2023, the patient has received her 7th blood transfusion during this hospitalization.
There is no medication reconciliation issue found in the patient.
[tube feeding]
{not completed}
{angioimmunoblastic T cell lymphoma, high grade with neck, inguinal, retroperitoneal LN metastases and generalized skin rashes, Lugano stage III, PS:0}
[lab data]
[exam findings]
[chemoimmunotherapy]
[family meeting minutes]
In the family meeting, the attending physician Dr. Gao explained the process and precautions of autoPBSCT to the patient and his family members (sister and brother-in-law). The patient expressed his willingness to fully cooperate. However, the patient has been married before and his only daughter is currently studying in the United States and is unaware of her father’s medical condition.
The patient’s family support may be insufficient before and after the scheduled transplantation. The nursing station will assist in coordinating caregiver arrangements. The attending physician reminded the patient to inform his daughter about his condition, and the patient indicated his understanding.
[diagnosis] - 2023-03-13 admission note
[past history]
Medical history: HTN, Chronic rhinosinusitis
Operation history: - glaucoma - s/p Parotidectomy, left、submandibular gland tumor excision, left - s/p Port-A insertion, L’t after L’t cephalic vein exploration
[allergy]
[family history]
Denied family history
[exam findings]
[chemoimmunotherapy]
[assessment]
[diagnosis] - 20221219 admission note
[exam findings]
[surgical operation]
[chemotherapy]
Based on the available lab data, serum Ca levels are stably lower than the normal range. If PTH secretion is insufficient to act on kidney, bone, and intestines, hypocalcemia may occur (hypoparathyroidism). No PTH lab data available. As the serum albumin concentration is also below normal, the low calcium level could also be due to a reduction in serum albumin levels.
Even when potassium supplements are taken intermittently, serum K readings remain below normal range since December 2022. An acute increase in hematopoietic cell production is associated with potassium uptake by the new cells and this may lead to hypokalemia. Administration of vitamin B12 or folic acid to treat a megaloblastic anemia or use of granulocyte-macrophage colony-stimulating factor (GM-CSF) to treat neutropenia are the most common scenarios in which this occurs.
[diagnosis] - 2023-03-12 admission note
[edu opinion] - 2023-03-12 admission note
History - Orbital lymphoma more commonly presents in the middle-age and the elderly. - Slowly progressing, and typically painless.
Signs - Conj: the typical lesion is salmon or flesh-pink color - Orbit, eyelid: when palpable, the masses are firm. - Lacrimal gland: an “S-shaped” mass due to the lateral location of the lacrimal gland - Proptosis - Ptosis and decreased levator function may indicate superior orbital and levator muscle involvement, and motility should also be measured if the patient complains of diplopia. - Signs are more commonly unilateral
Symptoms - Many lesions are asymptomatic but depending on the location of the mass, patients can complaint of exophthalmos, pain or diplopia, as well of conjunctival, eyelid, orbital or lacrimal gland mass.
Differential diagnosis - Benign lymphoproliferative lesions - Lymphoid hyperplasia - Systemic lymphoma - Metastasis - Amelanotic melanoma - Epithelial tumors - Inflammatory and infectious lesions - Orbital pseudotumor - Cavernous hemangioma
[past history]
[allergy]
[exam findings]
(145 - 47) / 145 - M-mode (Teichholz) = 68 - Prominent concentric LV hypertrophy and mild RV hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; moderately dilated LA. - Dilated LV with normal LV and RV systolic function. - Aortic valve sclerosis and mild aortic root calcification; mild MR; mild PR.
[consultation]
[chemoimmunotherapy]
[assessment]
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
The WBC count reached its lowest point approximately 7-10 days after the previous chemotherapy treatment in this patient, as indicated by the time relationship between the chemotherapy dates and the lab data recorded at this hospital.
Epirubicin can cause neutropenia (in 54% to 80% of patients; with grades 3/4 in 11% to 67%; nadir occurring at 10 to 14 days and recovery by day 21) and leukopenia (in 50% to 80% of patients; with grades 3/4 in 2% to 59%). ref: UpToDate
The prophylactic administration of G-CSF after chemotherapy may be considered around one week after treatment. Another option to consider is to moderately reduce the dose of epirubicin.
Cyclophosphamide use may lead to hemorrhagic cystitis, which can cause pyelitis, ureteral disease (ureteritis), and hematuria. Therefore, please closely monitor for any signs of these possible adverse reactions. Mesna can be used for the prevention of cyclophosphamide-induced hemorrhagic cystitis in cancer patients. Patients who have difficulty emptying their bladders are at a higher risk of developing bladder toxicity. If there is a clinical concern, a bladder ultrasound should be performed, and if there is a high post-void residual, the use of mesna is also appropriate for such patients.
[exam findings]
[consultation]
[chemoimmunotherapy]
diphenhydramine 30mg + granisetron 1mg diphenhydramine 30mg + granisetron 1mg diphenhydramine 30mg + granisetron 1mg diphenhydramine 30mg [assessment - appetite stimulant]
The patient reached his lowest recorded weight of 52.6kg on 2023-01-13, before slightly increasing to 54.6kg on 2023-02-24. The patient is currently receiving nutrition through a nasogastric tube and it is recommended to provide sufficient calories, protein, and other nutrients.
Previously in another pharmacist note, megestrol was recommended as an appetite stimulant, but if the patient cannot tolerate it and there is still a need for an appetite stimulant, Pilian (cyproheptadine 4mg/tab) might be also considered as an off-label alternative for decreased appetite due to chronic disease. The recommended dosage for Pilian is an initial 2mg four times per day for one week, followed by 4mg four times per day.
Quetiapine might then be considered as a last resort to increase weight, but it comes with the cost of dyslipidemia.
[assessment - pain control]
MXL (morphine 60mg/cap) 1# Q12H, fentanyl transdermal patch 50ug/h 2# Q3D, OxyNorm (oxycodone 5mg/cap) 2# Q4H have been properly prescirbed to deal with the backgroud pain.
NG tube OxyNorm administration: pour the small granules out of the OxyNorm capsules, dissolve them in drinking water, and pass them through the feeding tube.
If the patient still experiences breakthrough pain with a high VAS score, the addition of PRN morphine might be considered.
HGB 11.3 g/dL 2023-02-09 <- 6.5 g/dL 2023-02-06, in this case, anemia has been mitigated.
Platin- and taxel-based treatments have been administered to the patient.
2020 ASCO guidelines suggest that clinicians may offer duloxetine to patients with chemotherapy-induced peripheral neuropathy, and 2020 joint ESMO/EONS/EANO guidelines recommend duloxetine for treatment of neuropathic pain in this setting. ref: Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325. https://doi.org/10.1200/jco.20.01399
The platinum agents cisplatin and carboplatin are used both as single agents and to form the backbone for most combination regimens to treat metastatic and recurrent head and neck cancers. Although carboplatin is often considered to be less systemically effective than cisplatin in head and neck cancer, there is little direct evidence. Carboplatin may be preferred in some cases since it is associated with less neurotoxicity, nephrotoxicity, ototoxicity, and nausea and vomiting compared with cisplatin, although carboplatin causes more myelosuppression.
[duplicate note]
Since the patient has lost more than 10kg of body weight over the past 5 months (64.4kg 2022-09-17 -> 52.6kg 2023-01-13), possibly as a result of tumor-induced cachexia, it is recommended that the patient consume more and/or receive more intensive nutritional support. The addition of some appetizers, such as megestrol, might be beneficial.
Metoclopramide has been prescribed. The use of Emend (aprepitant) for antiemetic effect might be considered if nausea and/or vomiting is observed.
[exam findings]
[consultation]
{Diffuse large B-cell lymphoma, stage IV, with bilateral lung and adrenal gland metastasis. triple hit, IPI:4}
[diagnosis] - 2022-08-04 Discharge diagnosis
[exam findings]
[consultation]
[surgical operation]
[chemoimmunotherapy]
[problem list / assessment / plans]
Problem 1# triple hit, diffuse large B-cell lymphoma with bilateral lung and adrenal gland metastasis, Lugano stage IV, HCT-CI score: 0, IPI score: 4, High risk group, PS: 1 Assessment: autoPBSCT on 2023/02/24 (D0)
Plan
[assessment - Improvement in WBC Count Trend Observed]
[preparation and administration of mesna]
Mesna can be dissolved in 0.9% normal saline (NS) or 5% dextrose in water (D5W).
As the patient weighs 60kg, the scheduled (since 2023-02-21) dose of mesna is 12mg/kg, which means that 720mg of mesna should be dissolved in the aforementioned solvent no less than 50mL (final concentration no more than 20 mg/mL).
To ensure optimal administration, it is recommended that the injection lasts for no less than 30 minutes.
[exam findings]
[consultation]
[chemotherapy]
[assessment]
The patient’s renal function has declined, as evidenced by a decrease in creatinine clearance based on Cockcroft-Gault formula to 33mL/min as of 2023-03-06.
In patients with a CrCl between 25 and 50 mL/min, a recommended dose of 1g Q12H for meropenem is advised, compared to the intended dose of 1g Q8H.
By the way, there is no dosage adjustment necessary for any degree of kidney dysfunction for micafungin use. And there are no dosage adjustments for nystatin provided in the manufacturer’s labeling for patients with kidney Impairment.
{Squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence. Squamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0.}
[lab data]
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
[note]
2023-03-05 lab data CRP 5.25mg/dL.
2023-03-05 sputum gram’s stain result showed:
As the staining results may suggest a possibility of contamination, it may be necessary to collect a new sample.
Moxifloxacin with an antibacterial spectrum encompassing both aerobic gram-negative and gram-positive strains, as well as anaerobic bacteria, can be used for pneumonia, community-acquired, outpatients with comorbidities and inpatients as an alternative agent. It is not recommended to be used in patients with risk factors for P. aeruginosa (ATS/IDSA [Metlay 2019]; File 2020). Based on the normal liver and kidney function lab results on 2023-03-05, the current dosage of 400 mg once daily is appropriate and does not require any adjustments.
[tube feeding]
Broen-C (bromelain + L-cysteine) is an enteric-coated tablet designed to prevent the destruction of the bromelain enzyme by gastric juice.
Bromelain is sensitive to extreme conditions such as high temperature, gastric proteases in stomach juice, high acidity, and organic solvents, and thus, reduces its functionalities and bioavailability. Its instability under such stress conditions reduce its enzymatic activity, decrease its health benefits, and limit its pharmacological applications. ref: Mala T, Anal AK. Protection and Controlled Gastrointestinal Release of Bromelain by Encapsulating in Pectin-Resistant Starch Based Hydrogel Beads. Front Bioeng Biotechnol. 2021;9:757176. Published 2021 Oct 29. doi:10.3389/fbioe.2021.757176
There are no other drugs in the inventory that contain bromelain.
[tube feeding]
[tube feeding]
[tube feeding]
[tube feeding]
[exam findings]
[consultation]
[radiotherapy]
[chemoimmunotherapy]
[assessment]
Lab data
According to recent lab results, there is no longer leukopenia observed, but instead an overboosted WBC count accompanied by an elevated CRP reading (G-CSF administered on 2023-02-27). Please be aware of any signs of infection or inflammation. Anemia has gradually improved, and there is no observed thrombocytopenia.
The patient received injectable Amsulber (ampicillin + sulbactam) from 2023-02-23 to 2023-03-02 and has been taking oral Soonmelt (amoxicillin + clavulanic acid) since 2023-03-03. However, there has been no recent culture result available for the patient.
The laboratory results from 2023-02-28 also showed 4+ stool occult blood, which could be a possible cause of the anemia. It would be beneficial to rule out gastrointestinal bleeding before discharging the patient.
[exam findings]
[chemotherapy]
[assessment]
[exam findings]
[consultation]
[chemotherapy]
2023-03-01 - Vidaza (azacitidine) 75mg/m2 150mg SC D1-7
2023-02-02 - Vidaza (azacitidine) 75mg/m2 150mg SC D1-7
2021-05-17 ~ 2021-07-05 UFT (tegafur + uracil) KUFT01
[assessment]
Lab data
According to the lab data on 2023-03-01, leukopenia has improved in the patient. However, anemia is still progressing, and blood transfusion might be necessary.
Erythropoiesis-stimulating agents (ESAs) have been recommended as an effective treatment option for lower-risk MDS, including biosimilar epoetin alfa. ref: Epoetin alfa for the treatment of myelodysplastic syndrome-related anemia: A review of clinical data, clinical guidelines, and treatment protocols. Leuk Res. 2019;81:35-42. doi:10.1016/j.leukres.2019.03.006
In addition to leukopenia and anemia, the patient has been experiencing thrombocytopenia for years with no substantial improvement. Therefore, increased risk of bleeding should be carefully monitored and managed.
Thrombocytopenia is a significant problem in myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Eltrombopag, a thrombopoietin receptor agonist, has shown potential clinical activity in MDS and AML clinical trials. Studies have shown that eltrombopag is well tolerated and clinically effective in both low-risk and higher-risk MDS and AML patients. ref: Eltrombopag reduces clinically relevant thrombocytopenic events in higher risk MDS and AML. Lancet Haematol. 2018;5(1):e6-e7. doi:10.1016/S2352-3026(17)30229-6
There was another study evaluated the safety and efficacy of Eltrombopag in low to intermediate risk myelodysplastic syndromes (MDS) patients. The primary efficacy endpoint was hematologic response at 16-20 weeks, and 44% of the patients responded. The safety profile was consistent with previous studies, and Eltrombopag was effective in restoring hematopoiesis in these patients. ref: Eltrombopag monotherapy can improve hematopoiesis in patients with low to intermediate risk-1 myelodysplastic syndrome. Haematologica. 2020;105(12):2785-2794. Published 2020 Dec 1. doi:10.3324/haematol.2020.249995
[diagnosis]
[exam findings]
[chemoimmunotherapy]
[assessment]
This patient with Small cell B-cell lymphoma was treated with a total of six cycles of R-COP regimen from 2021-10 to 2022-03. However, during regular CT follow-up on 2022-11-25, progression of lymphadenopathy was observed in the mesenteric and paraaortic regions. As a result, the patient was rechallenged with R-COP from 2022-12 onwards.
The lab results from 2023-03-01 indicated that there were no notable abnormalities in the patient’s liver and kidney functions or blood cell counts. And the TPR panel revealed that the patient’s vital signs and blood pressure were stable.
Entecavir is prescribed to suppress the replication of the hepatitis B virus with no issue.
[present illness] - 2023-02-27 admission note
[past history]
[allergy]
[family history]
[exam findings]
[chemoimmunotherapy]
[G-CSF]
[assessment]
It is recommended avoiding the administration of filgrastim from 24 hours before to 24 hours after the administration of cytotoxic chemotherapy, due to the potential sensitivity of rapidly dividing myeloid cells to the cytotoxic effects of chemotherapy.
Filgrastim was administered on 2023-02-27 and chemotherapy is scheduled to be administered on 2023-03-01, with one day in between. Our administration pattern for the patient helps to uphold this principle without an issue.
[exam findings]
[surgical operation]
[chemoimmunotherapy]
[assessment]
A blood transfusion may be considered in light of the patient’s HGB level of 8.6 g/dL, PLT count of 31K/uL, and 4+ stool occult blood in 2023-02-28 lab results.
The sputum culture result 2023-02-28 revealed the presence of 1+ gram-positive cocci and 2+ gram-negative bacilli. Levofloxacin has been prescribed appropriately to target and treat these strains.
[present illness]
[past history] - 2023-02-25 admission note
[allergy]
[family history]
[exam findings]
[medication]
[assessment]
Based on the patient’s medication history of erlotinib followed by afatinib, it can be inferred that the disease is likely positive for EGFR exon 19 deletion or L858R, S768I, L861Q, and/or G719X mutations.
The patient had Grade 1 diarrhea which responded well to Smecta treatment (bowel movement of 3 times each day on 2023-02-27 and 2023-02-28). Additionally, the patient also experienced Grade 2 dermatitis and onychomycosis, which are currently being treated externally with tetracycline. If severe or prolonged diarrhea is not responding to antidiarrheal agents, GILOTRIF should be withheld to prevent dehydration and renal failure. In addition, GILOTRIF should be discontinued for life-threatening cutaneous reactions. Severe bullous, blistering, and exfoliating lesions occurred in 0.2% of patients. Severe and prolonged cutaneous reactions also require withholding of GILOTRIF.
After ground glass opacity was detected in bilateral lower lungs on the chest X-ray 2023-02-25, and G(+) Cocci were identified from sputum culture 2023-02-26, the afatinib treatment was temporarily suspended until the lung symptoms were relieved.
The current prescription is without any issue.
[diagnosis] - 2023-02-23 admission note
[past history] - 2022-12-08 admission note
[lab data]
[exam findings]
[surgical operation]
[chemoimmunotherapy]
The most common sequelae, or aftereffects, of axillary lymph node dissection (ALND 2022-08-11) are arm lymphedema, numbness, and limited shoulder mobility.
For patients with lymphedema (ie, International Society of Lymphology - ISL stage I, II, III), there is a recommendation to measure blood pressure in the contralateral arm, particularly in any setting in which blood pressure is being closely repeatedly or continuously monitored.
The effectiveness of these treatments in patients with established breast cancer-associated lymphedema (BCAL) is summarized below.
This (2023-02-24) morning, there was a decrease in blood pressure by 10mmHg resulting in a reading of 96/57, which should be noted. If the blood pressure continues to decrease, the administration of Concor (bisoprolol 5mg) may be suspended.
No medication reconciliation issues were found during this hospital stay, and the recently prescribed drugs disclosed in the NHI PharmaCloud System have been accurately prescribed as self-carried items that cover the patient’s underlying conditions.
[exam findings]
[assessment]
Based on the available lab data in HIS5, the patient’s HGB level has been consistently below the lower limit of normal since May 2020. The most recent HGB level recorded on 2023-02-23 was 7.4g/dL. It is recommended to closely monitor the patient’s ability to oxygenate.
For patients with chronic kidney disease-related anemia (2023-02-07 Ferritin 731.6ng/mL), the initiation of epoetin alfa or its biosimilars is generally recommended when Hb levels fall below 10 g/L, according to the Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. Reference: KDIGO clinical practice guideline for anemia in chronic kidney disease, published in Kidney Int Suppl in 2012;2(suppl):279-335.
Please evaluate if the detected bacteriuria (2023-02-24 lab result) indicates an asymptomatic UTI or not. Asymptomatic bacteriuria is common, but most patients with asymptomatic bacteriuria have no adverse consequences and derive no benefit from antibiotic therapy. With few exceptions, nonpregnant patients should not be screened or treated for asymptomatic bacteriuria.
{not completed}
[diagnosis]
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[radiotherapy]
[chemoimmunotherapy]
2023-02-23 - ramucirumab 8mg/kg 400mg NS 250mL 1hr + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4560mg NS 500mL 46hr (Cyramza + FOLFOX, Q2WK)
2023-02-03 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr
2023-01-15 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr
2022-12-30 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr
2022-12-16 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr
2022-06-13 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr
… … ..
2022-03-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
… … ..
2021-06-11 - irinotecan 180mg/m2 310mg D5W 250mL 90min + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2800mg/m2 4830mg NS 500mL 46hr
There is a possible trend towards leukopenia as the patient’s WBC count has gradually decreased over time.
The patient’s HbA1c levels have slowly increased and warrant attention.
Diarrhea seems to have improved as there was no bowel movement recorded on 2023-02-23.
The medications recently prescribed for the patient are in accordance with the records in the NHI PharmaCloud System, and have been correctly prescribed as self-carried items during this hospital stay to cover his underlying conditions. No issues related to medication reconciliation have been identified.
[past history]
Medical history:
Surgical: operation for endometriosis x3, 10+ years ago (open abdominal x1 + hysteroscopic x2)
Menstrual history: G0P0, Last menstrual period:2022/8/2
Has regular Pap smear examination (most recent 2022/08/03)
[allergy]
[family history]
[exam findings]
[surgical operation]
[chemoimmunotherapy]
[past history] - 2023-02-22 admission note
[allergy]
[family history]
[lab data]
[exam findings]
[SOAP]
[chemotherapy]
[assessment]
The use of 5-fluorouracil/mitomycin or capecitabine/mitomycin in combination with radiation for the treatment of anal cancer was considered (2023-02-10). A population-based study found that capecitabine/mitomycin and fluorouracil/mitomycin given concurrently with radiation achieved similar disease-free survival (DFS) and anal cancer-specific survival (ACSS). As such, substituting capecitabine for infusional 5-FU may be a viable option for patients and healthcare providers who prefer to avoid the potential complications and inconvenience of a central infusional device. (Reference: “A comparison between 5-fluorouracil/mitomycin and capecitabine/mitomycin in combination with radiation for anal cancer.” J Gastrointest Oncol. 2016;7(4):665-672. doi:10.21037/jgo.2016.06.04)
The mitomycin and fluorouracil with concurrent radiation (FUMIR) regimen was ultimately chosen for the patient. There are multiple variations of this regimen. The standard administration of 5-FU involves a continuous infusion over 4 days, specifically on Day 1-4 and 29-32. (ref: Mitomycin and Fluorouracil With Concurrent Radiation (FUMIR) Regimen for Anal Cancer. Hosp Pharm. 2013;48(6):464-469. doi:10.1310/hpj4806-464). Due to the patient’s advanced age, a 3-day infusion was utilized during this hospitalization, with a weekend break in between.
Lab results 2023-02-22 revealed that the CBC, WBC DC, Na, K, liver and kidney function were grossly normal, indicating no significant abnormalities.
In the review of systems section of the admission note (2023-02-22, yesterday), it was documented that the patient had been experiencing constipation for a period of two months, as well as anal bleeding with pain. The prescription of sennoside has been appropriately made. If anal bleeding persists, the addition of tranexamic acid may be considered as a potential treatment option.
A summary of the compatibility of mitomycin with various intravenous solutions is listed as following: mitomycin is not compatible with D5W, Dextrose 3.3% in sodium chloride 0.3%, and Dextrose 5% in water. Compatibility with D10W, D5LR, D5NS, 1/2NS, D5W-1/2NS and Ringer’s Injection is untested. IV compatibility with Normal saline (Sodium chloride 0.9%) is variable; Lactated Ringer’s Injection, Sodium chloride 0.4%, Sodium chloride 0.6%, and Sodium lactate 1/6 M is compatible.
This patient passed away at 10:19, 2022-11-03.
[lab data]
2023-06-26 CMV viral load assay Target not detecetedIU/mL
2023-06-19 CMV viral load assay Target not detecetedIU/mL
2023-06-12 CMV viral load assay Target not detecetedIU/mL
2023-03-14 CMV IgM Nonreactive
2023-03-14 CMV IgM Value 0.57 Index
2023-03-14 CMV_IgG Reactive
2023-03-14 CMV_IgG Value 393.8 AU/mL
2023-02-16 FLT3-D835 Undetectable
2023-02-15 BCR/abl Undetectable
2023-02-15 PML-RARA Undetectable
2023-02-13 FLT3/ITD Undetectable
2023-02-13 NPM1 Undetectable
2023-02-04 Anti-HBc Nonreactive
2023-02-04 Anti-HBc-Value 0.21 S/CO
2023-02-04 Anti-HBs 1.78 mIU/mL
2023-02-04 Anti-HCV Nonreactive
2023-02-04 Anti-HCV Value 0.09 S/CO
2023-02-04 HBsAg Nonreactive
2023-02-04 HBsAg (Value) 0.36 S/CO
2023-02-04 Anti-HBc IgM Nonreactive
2023-02-04 Anti-HBc IgM Value 0.10 S/CO
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
CYTARABINE (ARA-C) HIGH DOSE - Consolidation chemotherapy for AML in remission — https://nssg.oxford-haematology.org.uk/myeloid/protocols/ML-4-cytarabine-ara-c-3g-m2.pdf
ACUTE MYELOID LEUKAEMIA - CYTARABINE (3000mg/m2) — https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/AML/Cytarabine3000.pdf
{DLBCL}
[diagnosis] - 2022-07-31 discharge diagnosis
[lab data]
[exam findings]
[consultation]
[chemoimmunotherapy]
[exam findings]
[consultation]
[chemotherapy]
[tube feeding]
Keppra: In this hospital, there is a liquid form of Keppra oral solution (levetiracetam 100mg/mL, 300mL per bottle) that is suitable for tube feeding.
OxyNorm: Pour the small granules out of the OxyNorm (oxycodone 5mg/cap) capsules, dissolve them in drinking water, and administer them through a tube feeding.
OxyContin: OxyContin (oxycodone 10mg controlled-release tablet) is a long-acting formulation. Grinding the tablet will destroy the controlled-release design and cannot maintain long-lasting effects. Its use is not recommended for tube feeding.
[drug interaction]
Morphine (8mg IVD PRNQ6H currently) is contraindicated when used concurrently with monoamine oxidase inhibitors (MAOIs, linezolid 600mg IVD Q12H currently).
There is a possibility that monoamine oxidase inhibitors may enhance the adverse/toxic effects of morphine. Please monitor any possible adverse reactions carefully.
{Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and Rt retropharyngeal LAP metastasis s/p concurrent chemoradiotherapy on 2012/9/17 s/p 2nd PF on 2012/11/30}
[past history]
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[diagnosis] - 2023-01-16 admission note
[past history]
[allergy]
[family history]
[lab data]
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[assessment]
Except for urticaria, the underlying conditions listed in the problem list are appropriately treated with corresponding medications.
As a premedication, a single shot diphenhydramine is used in the current chemotherapy regimen, however, the newer, second generation H1 antihistamines are recommended as first-line therapy for urticaria. These newer drugs are minimally sedating, are essentially free of the anticholinergic effects that can complicate use of 1st generation agents, have few significant drug-drug interactions, and require less frequent dosing compared with first-generation agents. It is recommended to initialize a 2nd generation antihistamine at standard therapeutic dose:
{not completed}
[exam findings]
2023-02-08, -02-05, -01-31 CXR
2023-02-05 CT - brain
2023-02-03 MRI - brain
2023-02-03 Electroencephalography, EEG
2023-02-03 Peripheral Vascular Test - vein, lower limbs
…
…
…
lab data
surgical operation
radiotherapy
chemoimmunotherapy
2023-01-23 urine culture found Candidas abicans 50000 colony count CFU/cc. Treatment of candidemia and invasive candidiasis in nonneutropenic patients could be an echinocandin (1. caspofungin 70 mg IV loading dose, then 50 mg IV daily; 2. micafungin 100 mg IV daily; 3. anidulafungin 200 mg IV loading dose, then 100 mg IV daily. Items 2 and 3 are not necessary to be dose adjusted for any degree of kidney impairment and they are available in this hospital.) is recommended as initial therapy. (ref: https://www.uptodate.com/contents/image?imageKey=ID%2F87676)
2023-01-13 anaerobic culture of the perineuim was found to contain Bacteroides thetaiotaomicron 3+ that was sensitive to metronidazole and ampicillin/sulbactam. It is not necessary to adjust dose for metronidazole if CrCl is greater than 10, while for ampicillin/sulbactam, CrCl is greater than 30. Keep metronidazole use is recommended.
If Keppra (500mg Q12H) is not demonstrated to be effective for seizure control, valproate (no dosage adjustment necessary if CrCl >= 10 mL/min) or carbamazepine (no dosage adjustment necessary for kidney impairment) might be added.
[compatible solutions to mitigate hypernatremia that do not rely on saline]
Following is a list of the selected injectable medications in the active prescription and their compatibility with non-saline-based solutions according to MicroMedex.
Use potassium supplements if necessary
WBC returned to 5.05K/uL on 2023-02-12, neutropenia not observed.
[diagnosis] - 2022-12-02 admission note
[past history]
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemoimmunotherapy]
[exam findings]
[chemotherapy]
[assessment]
[diagnosis] - 20230203 admission note
[past history]
[allergy]
[exam findings]
[consultation]
[chemotherapy]
[medication]
{not completed}
[exam findings]
[diagnosis] - 2023-01-12 discharge note
[Past History]
[Family History]
[lab data]
[exam findings]
[surgical operation]
[radiotherapy]
[chemotherapy]
[assessment]
[potential drug interactions]
Flunarizine (patient-carried) is cocommitant with clonazepam, diphenhydramine, estazolam and fexofenadine currently.
According to the flunarizine product monograph (https://www.aapharma.ca/downloads/en/PIL/2021/Flunarizine_PM_EN.pdf), use of CNS depressants, including alcohol, should be avoided during treatment with flunarizine due to the risk of excessive sedation.
There is also an antivertigo preparation available in stock known as Nilasen (betahistine 24mg/tab), which has a lower risk of drug interaction than flunarizine and can be considered as a 1# daily dosage alternative.
There is no specific pharmacist shift handover to follow in this patient.
[drug identification]
[diagnosis] - 2023-02-01 discharge note
[lab data]
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[diagnosis] - 2023-02-01 discharge note
[lab data]
[exam findings]
[surgical operation]
[radiotherapy]
[chemotherapy]